Medical Intake form

Ascend Health Primary Care Enrollment Questionnaire

At the end of this intake form, you will have the option to select your membership level and enroll. If multiple family members are enrolling, please list their information when prompted.
Name

First NameMiddle NameLast Name
Person Filling Out This Form (if not the Patient)

Full NameRelationship to patient
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender
Marital Status
Occupation
Emergency Contact

Full NameCell Phone Number
Did something trigger your change in health?
Preferred Pharmacy

Pharmacy NamePharmacy Location
Pharmacy Phone Number
Format: (000) 000-0000.

List all household members who will be included in your DPC membership.

Rows	Full Name	Birthdate	Gender	Health Concerns
Spouse
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

How often do you drink alcohol?
Which of the following characterize your tobacco use?
Please list any recreational drugs.
Are you sexually active?
Screenings

If you have ever had any of the following screenings, please provide approximate date.

Did your recent PAP include HPV co-testing?
Blood type, if known. (Ex: A+, O-, etc.)
Vaccinations
Did you receive your childhood vaccinations?
Which of the following vaccinations have you received?
Allergies
Do you have any allergies?
If yes, please list and describe your reaction.
Do you have any drug allergies?
If yes, please list and describe your reaction.
Sexual Health
What is your sexuality?

Other
Have you ever been diagnosed with or tested positive for a sexually transmitted disease?
Medical History

Rows	Approximate date of last screening
Colonoscopy
Mammogram
DEXA Scan
PAP Smear
TB Test

Family History

Rows	Mother	Father	Sibling	Children	Mat. Grandparent	Pat. Grandparent
Cancers
Colon
Breast/Ovarian
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory arthritis
Inflammatory Bowel Disease
Multiple Sclerosis
Autoimmune Diseases
Irritable Bowel Syndrome
Celiac Disease
Asthma
Eczema/Psoriasis
Food allergies/sensitivities
Environmental sensitivities
Dementia
Parkinson's
ALS or other motor neuron diseases
Genetic disorders
Substance abuse (alcoholism, etc.)
Psychiatric disorders
Depression
Schizophrenia
ADHD
Autism
Bipolar disease

Medical History

Select all that apply.
Surgical History:

Other
Gastroenterology Related Medical History:
Cardiology Related Medical History:

Other
Endocrine Related Medical History:

Other
Nephrology Related Medical History:

Other
Orthopedics Related Medical History:

Other
Immune System Related Medical History:

Other
Lung Related Medical History

Other
Dermatology Related History:

Other
Cancer History:

Other
Mental Health/Neurology Related History:

Other
If you selected "other" to any of the above sections, please explain below.
Women's Health History:

Current Birth Control Method
Menopausal patients
Men's Health History

Other
List all current medications with dose and frequency.

Rows	How many?
Pregnancies
Full-term Births
Pre-term Births
Miscarriages/Stillbirths
Abortions

Insurance Information

Optional, but helpful in the event of medical emergency or referral to specialist.
Insurance Carrier
Policy Number
Group ID Number
Name of insured (if different from patient)

First NameLast Name

Confidentiality Statement (HIPAA)

We are committed to protecting the privacy and confidentiality of your health information in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Your medical records are maintained securely, and access is limited to those involved in your care, billing, or clinic operations as permitted by law. Information will not be disclosed to anyone outside of these circumstances without your written authorization, except as required or permitted by law.
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Authorization for the Release of Medical Information

I hereby authorize Ascend Health to release or discuss my protected health information (PHI), including but not limited to medical records, test results, diagnoses, treatment plans, and billing information, to the following individual(s):
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What information may we share with the individual listed above?

Other
This authorization shall remain in place until:

Other
Patient Rights

I understand that I may revoke this authorization at any time by providing a written request to Ascend Health. Revocation will not affect disclosures already made in reliance on this authorization. I understand that once information is released to the authorized individual(s), it may be subject to re-disclosure by them and may no longer be protected by HIPAA. I am not required to sign this authorization to receive treatment.
Signature
Date

MonthDayYear
Date

Request for Release of Medical Records

I authorize release of my medical information as indicated below. I understand that this authorization is voluntary ad may include information related to mental health, substance use, or HIV testing unless otherwise limited. I may revoke this authorization at any time in writing, but it will not affect any disclosures made prior to that revocation.
Patient Information

Full NameDate of Birth
Release records from:

Provider or FacilityAddress/Phone/Fax
I authorize the release of my full medical record from the provider listed above to Ascend Health.
Release To:

Ascend Health 3051 Kirby Whitten Pkwy Ste. 5, Bartlett, TN 38135 Phone: 901-352-5858 or Fax: 901-621-7950
Signature

Acknowledgement of Receipt of Advance Directive Information

An advanced health care directive, also known as a living will, personal directive, or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. In the U.S., it has a legal status in itself, whereas in some countries it is legally persuasive without being a legal document.
I have completed an Advance Directive or health care:
If yes, please indicate which:
I would like more information regarding Advance Directives:
Membership Terms

By signing below, I acknowledge and agree to the following: I understand and accept the one-time enrollment fee of $100 and the ongoing monthly membership fee. I authorize Ascend Health to automatically draft monthly payments from my designated account on the date of enrollment each month. I understand that cancellation requires one month written notice and that an additional monthly fee may apply during the notice period. I understand that medical care and services under this membership will not continue after cancellation unless I choose to reactivate. I understand that my medical records will remain accessible regardless of membership status.
Signature
Date

MonthDayYear
Date

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Ascend Health Primary Care Enrollment Questionnaire

Screenings

Vaccinations

Allergies

Sexual Health

Medical History

Medical History

Insurance Information

Confidentiality Statement (HIPAA)

Authorization for the Release of Medical Information

Patient Rights

Request for Release of Medical Records

Release To:

Acknowledgement of Receipt of Advance Directive Information

Membership Terms

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