Patient Demographic Sheet - St. Joseph Medical Center

Date: _____________Patient Demographic SheetName:Mark Fraiman M.DRichard Mackey M.D.________________________________________________________________________(First) (MI) (Last)Social Security# _______________________ Date of Birth_______________________Age: __________Gender: Male/ FemaleMarital Status: ____Single ____Married ___ Widowed ____ Divorced ____SeparatedAddress_________________________________________________________________City/State_______________________________ ZIP_____________________________Phone: (H) ________________________(W/Cell) ____________________________Spouse/Significant Other name: ____________________________________________Date of Birth _______________________ Phone ______________________________Emergency contact person: ____________________________Phone________________Employment Status:___Fulltime ___ Part time ____ Retired ____UnemployedPrimary Care Doctor:_____________________________________________________________________(First Name)(Last Name)Phone: ____________________________________Referring Doctor:______________________________________________________________________(First Name)(Last Name)Phone: ____________________________________

MEDICATION SCREENINGAre you currently on any blood thinners? YES/NOIf yes, please check which one below.____ Coumadin _____ Warfarin _____ Plavix _____ OtherDosage/Frequency: _________________________________Are you Diabetic? YES/NOPLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKINGPLEASE INCLUDE DOSAGE & FREQUENCY(If you have a list, we can make a copy)____________________________________________________________________________________________________________________________________________________________________________________________________________________________ARE YOU ALLERGIC TO ANY MEDICATIONS OR HAVE ANY ALLERGIES? YES/NOPLEASE LIST THEM BELOWNAMEREACTION/ SIDE EFFECTS1. _____________________________ ________________________________2. _____________________________ ________________________________3. _____________________________ ________________________________NEW/CHANGED MEDICATION INSTRUCTIONS: (for internal use only)NameInitial & date__________________________________________ ____________________________________________________________ ____________________________________________________________ __________________*I understand the above information and will receive a copy of this form if I request it*SIGNATURE: ___________________________ DATE:________________________

Insurance: PrimaryName: _____________________________________________Policy number _______________________ Group number: ________________Subscriber Name: ______________________ Subscriber Date of Birth__________Insurance: SecondaryName: ______________________________________________Policy number _______________________ Group number: ___________________Subscriber Name: ______________________ Subscriber Date of Birth ___________I understand and agree that regardless of my insurance status, I am ultimately responsible for the balanceof my account for any professional services rendered. I will notify you of any change in my status inregards to the above information. I consent to the care including diagnostic procedures, examinations andtreatment that the physician designates and considers to be necessary to treat my condition. I certify that Ihave read all information on this sheet and have answered all questions to the best of my knowledge.SIGNATURE: _______________________________ DATE: ____________________NOTICE OF PRIVACY PRACTICESThis notice describes how medical information about you may be used and disclosed by:Mark H. Fraiman M.D. and Richard A. Mackey Jr. M.D.o We have the legal duty to protect health information about you.o We may use and disclose protected health information about you without your authorization in thefollowing circumstances:o To provide health care treatmento To obtain payment for serviceso To perform healthcare operations/ functionso When required by law, necessary for public health, victim abuse, neglect or domesticviolence, health oversights (overseeing health operations), judicial and administrativeproceedings, law enforcement purposes, relates to decedents (coroner or medical examiner)organ, eye or tissue donation, medical research, averting a serious and eminent threat to publichealth and safety, specialized government functions, correctional institutions and law enforcementcustodial situations.ooTo provide appointment remindersTo contact you with information about treatment, services, products or health care provider(NEXT PAGE)

oYou have several rights regarding your protected health information. You have the right to:Request restrictions on uses and disclosure of your PHIRequest alternative options for us to communicate with youRequest copy of your PHIRequest amendment of your PHIRequest listing of disclosures madeRequest copy of this noticeo You may file a complaint, in writing about our privacy practices if you feel we have violatedyour rights. If you file a complaint we will not take any action against you or change yourtreatment in any way.o Effective date of this notice is April 14,2003oI hereby authorize and request release of medical records to Dr. Fraiman & Dr. Mackey forthe purpose of providing appropriate health care treatment as determined necessary byDr. Fraiman and/or Dr. MackeySIGNATURE ______________________________ DATE _______________________