pa t e ship ith ou. Ou goal is to i p o e the health of all patie ts th ough ea l tee s to
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- Barnard Baker
- 5 years ago
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Transcription
1 Dea Patie t, Tha k ou fo hoosi g Ha ou Wo e s Health. You ha e ade a hoi e to joi a g oup that st i es to p o ide the est i o e s health a e. We a e dedi ated to helpi g patie ts i a o fo ta le, o judg e tal e i o e t ith a at osphe e of utual espe t a d t ust. Ha ou Wo e s Health p o ides oad spe t u o stet i al a e a d g e ologi al a e that is oth i o ati e a d e ide e ased. Ou k o ledge is sha ed a d t a spa e is sought ith a e phasis o safet, e de elop o ti uous heali g elatio ships o ki g i pa t e ship ith ou. Ou goal is to i p o e the health of all patie ts th ough ea l tee s to e opause ea s a d e o d. Ou p a ti e e phasizes p e e tati e a e a d is o e ed ith ou total ell ei g. If o ple e ta edi i e is pa t of ou health a e philosoph, ou ll fi d ou p a ti e suppo ts this hoi e. I additio to the o sults offe ed ou ph si ia s a d ou u se p a titio e s; Ha ou Wo e s Health p o ides a additio al se i es i ludi g: ult asou d se i e; a edited th ough the A e i a I stitute of Ult asou d i Medi i e AIUM, a d i offi e su gi al p o edu es. I additio e offe edu atio al se i a s a d o kshops fo ou o u it Ha ou Wo e s health st i es to u o ti e, ut so eti es u i g late a ot e a oided as e a e doi g the est e a to a e fo ea h a d e e patie t s eeds. So e a s ou a help the p o ide s u o ti e is a i i g fiftee i utes p io to ou appoi t e t ti e fo he k i a d o pletio of pape o k. Du i g ou fi st appoi t e t ith ou offi e, please i g ou photo ID a d i su a e a ds. As a effo t to p o ide ette o u i atio et ee p o ide s a d patie ts, e i ite all patie ts to joi ou patie t po tal. Ou f o t desk staff ill e happ to assist ou i sig i g up fo the patie t po tal. The po tal lets ou se d essages to ou p o ide, ie la esults, isit su a ies a d o e. Ou offi e hou s: a. p. Mo da th ough Thu sda a. th ough : p. F ida Please e a a e ou pho e li es lose i utes p io to offi e losu e. Please let us k o if ou e ui e a spe ial se i es, su h as a i te p ete o othe spe ial eeds he ou s hedule ou appoi t e t.
2 Calli g ith edi al o e s? Whe e e ou ha e a edi al p o le o o e du i g offi e hou s, please feel f ee to o ta t ou offi e. Ou staff a a s e a of ou uestio s a d ill help ou de ide hethe ou should o e i to see ou p o ide If ou lea e a essage i ou u si g staff s oi e ail o the ill e su e to etu a all to ou the sa e da Messages e ei ed ia the patie t po tal ill e etu ed ithi usi ess da If ou p o le is u ge t please ad ise the s it h oa d ope ato a d she ill get ou i ediate assista e. Whe ou all fo a p es iptio efill, ou s it h oa d ope ato ill o e t ou to ou P es iptio Pho e Mail o Ou li i al staff liste s to this li e a ti es dail a d ill o u i ate ith ou pha a as ui kl as possi le. You a e pe t ou pha a to e ei e the efill o de s ithi hou s. If, i a e e ge, ou eed to ea h us afte hou s su h as ights, eeke ds, o holida s, all The a s e i g se i e ope ato ill page the Ph si ia o all. As page s a e ot i falli le, please epeat ou all if ou ha e ot hea d a k f o so eo e ithi i utes. Tests a d test esults: The f e ue of s heduled la o k, lood tests a d diag osti s ee i g is ased o ou age a d isk fa to s. A o all of these tests a ot e e essa at e e e a Please talk to ou p o ide a out the f e ue app op iate fo ou. We ill ot outi el all ith ost NORMAL esults of la tests. You ill e ei e i fo atio ou patie t po tal to i fo ou of ou o al esults ithi th ee eeks. We ill all ou as soo as possi le ith a ABNORMAL esults. If ou e ui e the esults of a spe ifi tests p io to e ei i g the otifi atio ; the ou a all ou offi e, gi i g us da s to e ei e ou esults. Offi e Staff: All of us at Ha ou Wo e s Health o k as a tea to e su e that ou e ei e the est possi le a e a d se i e. Ou staff e e s a e he e to a s e ou illi g a d health i su a e uestio s, as ell as s hedule ou appoi t e ts. Ou u si g staff is a aila le to help ou ith edi al uestio s o o e s. Please i ui e th ough ou patie t po tal o ou s it h oa d ope ato e ill o e t ou ith the staff e e ho a est eet ou eeds. O e agai, tha k ou fo e t usti g Ha ou Wo e s Health ith ou health a e. We look fo a d to o ki g ith ou o a d i the ea s ahead to a i ize ou health a d ell ei g. Si e el, The Staff of Harbour Women s Health
3 I su a e a d Pay e t Poli ies We a e so that e ust ask ou a out ou i su a e o e age up f o t. We ould e tai l p efe to o e t ate o l o patie t a e. Whe e o t a tuall ag ee to pa ti ipate ith a i su a e o pa it e ui es us to follo spe ifi p o edu es a d guideli es ith thei o pa We a e e ui ed to do p e autho izatio fo e tai p o edu es, o tai a efe al p io to ou isit, e t. I o de to eet these i su e e ui e e ts, e ha e o hoi e ut to get i fo atio f o ou efo e ou a e see Tha k ou fo ou patie e Patie t pa e t espo si ilit is e ui ed upo he k i at the f o t desk the da of ou appoi t e t u less p e ious a a ge e ts ha e ee ade ith ou illi g depa t e t. Ou s heduli g o illi g staff ould e happ to assist ou ith app o i ate ost fo se i es. Cu e tl, Ha ou Wo e s Health a epts ash, he ks Visa, Maste Ca d a d Dis o e as pa e t fo se i es. Offi e Visit Poli y We ha e o t a tual ag ee e ts ith the follo i g i su e s a d ill ill ou i su a e fo ou. Natio al Blue C oss Blue Shield Pla s Fede al Blue C oss Blue Shield A the HMO Blue of NH/NE A the Blue Choi e of NH/NE Ha a d Pilg i Health a e U ited Health a e Ma ti s Poi t NH Medi aid T i a e Sta da d Medi a e Aet a Health a e O e Health Pla PPO Cig a If ou a e o e ed a i su e ot listed a o e, pa e t is e pe ted at the ti e of se i e. You ill e p o ided ith illi g i fo atio to su it to ou i su a e o pa If ou e ui e ou offi e to se d la spe i e s to a e tai pha a that o t a ts ith ou i su a e o pa please alert the li i al staff at the ti e of your visit. Medi ally Ne essa y Su ge y / P o edu e Poli y E a ples of this t pe of p o edu e i lude olpos op, e do et ial iops, osu ge, LEEP, so oh ste og a, a d h ste os op If ou a e o e ed i su a e, hethe o ot e o t a t ith the, e ill ill ou i su e fo a se i e o e $ If e do su it ou lai to ou i su a e o pa e ill o ta t ou i su e fo the esti ated patie t pa e t espo si ilit a d e ill e pe t this pa e t po tio p io to ou se i e. If ou a e ot o e ed o e of these i su e s, e ust ask fo % pa e t at the ti e of se i e fo p o edu es ith a ha ge u de $ We ill p o ide ou ith lai i fo atio so that ou a su it the se i e to ou i su a e o pa fo ei u se e t. If ou ha e a uestio ou a o ta t ou illi g depa t e t. The ill e happ to assist ou. If ou ha e o i su a e a d a e e pe ie i g e o o i ha dship, please all ou illi g depa t e t p io to ou s heduled appoi t e t to a a ge a pa e t pla Please see e e se side fo o e i fo atio
4 Ele ti e P o edu e Poli y So e e a ples of ele ti e p o edu es a e i fe tilit t eat e ts, I pla o i se tio s, IUD i se tio s, lapa os opi tu al ligatio s, e o i u isio, a d so e U og e ologi se i es. Ma i su e s do ot o e ele ti e p o edu es, a d he the do, pa e t a ies idel f o i su e to i su e If ou a e o side i g a ele ti e p o edu e please all ou i su e to e ie ou poli, the all us to e uest pa e t i fo atio f o ou illi g depa t e t. Refu d Poli y O asio all, a i su e a pa o e tha o igi all esti ated fo a gi e p o edu e a d ou a e due a efu d o ou pe so al pa e t. You a e pe t a p o pt efu d fo a o e pa e t o e $ o e ou i su e ei u ses Ha ou Wo e s Health. A efu d due ou of $ o less ill e kept o ou a ou t as a edit to a d futu e se i es, ho e e e a e happ to se d ou i ediate ei u se e t upo e uest. Refe al Poli y All i su e s do ot e ui e a efe al fo ea l isits o o stet i al a e. The e a e a fe i su e s that ill e ui e a efe al fo othe isits. Please otif ou i su e o ou p i a a e p o ide to la if ou eed fo a efe al fo spe ifi se i es. We ust e ei e the efe al p io to the da of ou isit. If a uestio should a ise i ega d to hethe o ot ou efe al is i pla e, ou a o ta t ou f o t offi e staff. Usual a d Custo a y Rei u se e t So e i su e s ith ho e do ot ha e o t a ts ill ot ei u se ou fo ou full fee, ased o hat the all Usual a d Custo a Cha ges This is a a i hi h so e i su e s fu the edu e osts a d e do ot ase ou fees o thei Usual a d Custo a dis ou ts. If ou pa e t is edu ed i this a ; e s pathize ith ou f ust atio ut ust ill ou set fees. A Note A out Missed Appoi t e ts We keep a aiti g list fo patie ts, so e ith u ge t p o le s, hopi g to get a ea lie appoi t e t. If ou fi d ou a ot keep ou s heduled appoi t e t, a all at least hou s i ad a e ill allo us to offe ou appoi t e t to a othe patie t. We ust ha ge fo appoi t e ts issed ithout hou s oti e. Tha k ou fo ou u de sta di g. Ou offi e is al a s happ to help ou ith a o e s ou ha e ega di g the a e a d se i e ou e ei e f o Ha ou Wo e s Health. Ho e e, si e the e a e hu d eds of i su e s, ea h ith a diffe e t t pes of p og a s, e a, ho e e, e of little help a s e i g uestio s o o plai ts a out ou i su a e o e age. I additio e a ot e espo si le fo k o i g hat ou i su a e ill pa fo se i es. Please all the Custo e Se i e u e o the a k of ou i su e ID a d to fi d out ou i su a e o e age o to e p ess ou o e s ith ou i su a e o pa You should also sha e ou o e s ith ou e plo e
5 Co se t to T eat, Use P ote ted Health I fo atio Fo T eat e t, Pay e t a d Health Ca e Ope atio s a d Health a e Pay e t Respo si ility THIS DOCUMENT MAY NOT BE ALTERED IN ANY WAY If you ha e uestio s a out this do u e t, please ask the f o t desk. I o se t to diag osis o t eat e t of e a p o ide of Ha ou Wo e s Health. I o se t to allo Ha ou Wo e s Health to use o dis lose p ote ted health i fo atio fo t eat e t, pa e t a d health a e ope atio s. T eat e t ea s the p o isio, oo di atio, o a age e t of health a e a d elated se i es o e o o e health a e p o ide s. Pa e t ea s the a ti ities u de take a health a e p o ide o health pla to o tai o p o ide ei u se e t fo the p o isio of health a e Health a e ope atio s ea s o du ti g ualit assess e t a d i p o e e t a ti ities; e ie the o pete e o ualifi atio s of health a e p ofessio als; u de iti g, p e iu ati g, a d othe a ti ities elated to health i su a e o t a ts; edi al e ie s; legal se i es; auditi g fu tio s; a d usi ess a age e t a d ge e al ad i ist ati e a ti ities of Ha ou Wo e s Health. I o se t to allo Ha ou Wo e s Health to dis lose p ote ted health i fo atio fo t eat e t a ti ities of a othe health a e p o ide I o se t to allo Ha ou Wo e s Health to dis lose p ote ted health i fo atio to a othe o e ed e tit o to a othe health a e p o ide fo the pa e t a ti ities of the e tit that e ei es the i fo atio I o se t to allo Ha ou Wo e s Health to dis lose p ote ted health i fo atio to a othe o e ed e tit fo health a e ope atio s a ti ities. The dis losu e ust e fo t eat e t, pa e t, o othe health a e ope atio s o fo the pu pose of othe health a e appli a le la s. I he e assig to Ha ou Wo e s Health all pa e ts fo edi al se i es e de ed to depe de ts o self. I u de sta d that I a espo si le fo a a ou t ot o e ed i su a e. I ha e ead a d I u de sta d the a o e i fo atio Na e of patie t Please P i t Sig atu e of Pe so Autho izi g Co se t Date Relatio ship to Patie t
6 Date: Last Na e Fi st Na e P e ious Na e Add ess Cit, State, Zip Date of Bi th So ial Se u it Nu e fo edi al e o ds pu poses Ge de Fe ale Male T a sge de Whe e all ou, please i di ate YES o NO, hethe e a lea e p i ate essages ide tif i g ou sel es M Ho e Pho e Nu e is: B ief Message O l Yes No E te ded Message Yes No M Cell Pho e Nu e is: Yes No Yes No M Work Pho e Nu e is : Yes No Yes No Whe e do ou o k? Wo k Add ess: P i a Ca e Ph si ia Fi st & Last Na e PCP Cit, State: You E e ge Co ta t s Na e: Thei Pho e Nu e : Relatio ship to ou: You I su a e: Who is the su s i e : Relatio ship to ou: Thei DOB: Su s i e s Add ess: You E ail Add ess:
7 We a e e ui ed to ask these uestio s due to Fede al Mea i gful Use Ruli g. Please e assu ed that all i fo atio is kept u de ou usual st i t o fide tialit guideli es. Please i le ou espo ses to the follo i g uestio s: Ra e A e i a I dia o Alaska Nati e Asia Nati e Ha aiia Eth i ity Hispa i o Lati A e i a Not Hispa i o Lati A e i a Refuse to Repo t Bla k o Af i a A e i a White Hispa i Othe Pa ifi Isla de Othe U epo ted / Refused Pri ary La guage E glish Spa ish Othe : P efe ed Lo al Pha a ou p es iptio s ill e se t he e u less e uested othe ise Pha a Add ess: Do ou ha e a li itatio s, suppo ts eeded, se i es e ui ed o disa ilit eeds of hi h e should e a a e? YES NO If Yes, please e plai : Do ou eed assista e getti g o to a e a ta le? YES NO Patie t Sig atu e:
8 Health History Questio aire Na e: Date: Date of Bi th: Medi al History: Please list a MEDICATION/ DRUG ALLERGIES a d the t pe of ea tio ou had: Please list edi atio s p es iptio s a d o p es iptio s, ita i s o supple e ts ou a e taki g: Na e of Medi atio Dose & Ti es pe da Fo hat easo? Ho Lo g? P es i ed? Please list a edi al p o le s: Please list all su ge ies a d hospitalizatio s ou ha e had a d the app o i ate ea i hi h the o u ed, i ludi g to sils, he ias tu al ligatio s, et Please i di ate if ou ha e e e had a lood t a sfusio Me ses Age ou pe iod e ses sta ted Stopped e opause A e the egula? Yes No Nu e of p eg a ies Co e s a out ou pe iod? Yes No Me opause Co e s? Yes No Nu e of li e i ths Pai o leedi g ith I te ou se? Yes No A o al pap s ea s? Yes No Nu e of is a iages P o le s o t olli g u i e? Yes No With ough, s eeze o e e ise Nu e of a o tio s Health S ree i g a d Preve tative A tivities: Whe as the last ti e ou had: Ph si al E a : Pap S ea : Choleste ol S ee i g : Ma og a : Teta us Shot: PPD TB test :
9 Na e: Date of Bi th: Behaviors a d Ha its Affe ti g Health: Please des i e ou use of to a o p odu ts: Ci le: Ne e S oked Still S oke Quit S oki g Ho a pa ks pe da did ou o do ou s oke? Ho a ea s? Ci le: I a t to uit No Soo E e tuall Ne e Did Quit? Whe Ho Mu h al ohol do ou d i k o a e age? Do ou ha e o e s a out ou al ohol use? Yes No Ho u h affei e do ou d i k dail offee, tea, soda? Please i le o he k a of the follo i g that a e t ue fo ou E e ise egula l S oke dete to at ho e Do self east e a Eat lo fat diet Fi e e ti guishe at ho e Wea Seat elt Gu i ho e Gu se u ed f o hild e Ha e a li i g ill Wea a hel et if iki g / olle ladi g What is ou se ual o ie tatio Ho ose ual Hete ose ual Bise ual Do ou p a ti e safe se? Ne e So eti es Al a s If eeded, hat t pe of i th o t ol ethod do ou use: Do ou ha e a uestio s a out i th o t ol? Yes No Se ual Fu tio i g? Yes No So ial History: Who li es i ou household? Do ou feel safe at ho e? O upatio? K o haza dous e posu es at o k? A e ou i te ested i : Li i g Will: Yes No O ga Do atio : Yes No Do ou ha e a spe ial o e s that ou ould like to dis uss toda? Tha k You! Re ie ed :
10 Fa ily Medi al History Questio aire Date: Na e: Date of Bi th: Please ite i the spa es p o ided, a edi al o ditio s of ou fa il e e s. Please i lude age, if still li i g, o ause of death a d age of death if de eased. Co side so e of the follo i g edi al o ditio s: High lood p essu e High holeste ol Hea t Atta k St oke Dia etes B east Ca e Colo Ca e / Pol ps Othe Ca e Asth a Seizu es D ug / Al ohol A use Glau o a Th oid P o le s Bleedi g Diso de Me tal Ill ess Mothe : Fathe : B othe s : Siste s : Child e : Mothe s Mothe : Mothe s Fathe : Fathe s Mothe : Fathe s Fathe : Othe : Tha k You! Re ie ed :
11 Date Na e Wel o e to ou p a ti e a d tha k ou fo hoosi g Ha ou Wo e s Health fo ou health a e. We d app e iate ou help i letti g us k o ho ou fou d us: F ie d/neigh o /Relati e Na e: Add ess: I do I do ot autho ize Ha ou Wo e s Health to pe so all tha k the a o e fo efe al Refe al f o a Ph si ia / Nu se P a titio e / Health a e P o ide Na e: Yello Pages Hospital Refe al Se i e Fa e ook We site: Health I su e Othe : Tha k you fo taki g the ti e to gi e us this i fo atio!
12 Di e tio s to ou offi e Ha ou Wo e s Health is lo ated at 55 G iffi Road, Po ts outh, NH 38 Di e tio s f o Mai e o No the NH: Take I E it B a d tu ight at the stoplight. Go to the th stoplight a d tu ight o to G iffi Road. The Ha ou Health Buildi g is the o l edi al uildi g o the left. Di e tio s f o Ha pto o Bosto : Take I E it a d tu ight at the stoplight. Go to the d stoplight a d tu ight o to G iffi Road. The Ha ou Health Buildi g is the o l edi al uildi g o the left. If at a ti e du i g ou t a els ou ha e uestio s as to ho to lo ate ou offi e, please gi e ou offi e a all a d ou f o t desk staff ill e happ to assist ou ith di e tio s. Ou pho e u e is:
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