Registration - Tucson Independent Physicians and Surgeons

Complete the form below and it will be securely sent to your specialist‘s office.

"*" indicates required fields

Step 1 of 12 – Personal Information

Provider*

Which surgeon will you be seeing?

First name*

Middle Name

Last name*

Preferred Name

Social Security

Birth Date*

Month

Day

Year

Birth state

Age*

Height

Weight

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partnerid

filled automatically based on other fields. Used for to validate permissions on form entries

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partneremail

filled automatically based on other fields. Used for to validate permissions on form entries

Birth Sex*

Female

Male

Preferred pronoun

Current Gender

Female

Male

Choose not to disclose

Other

Gender Identity

Female

Male

Choose not to disclose

Other

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Sexual Orientation (ARCHIVED)

Straight or heterosexual

Choose not to disclose

Bisexual

Lesbian, gay, or homosexual

Don’t know

Other

Contact Information

Primary Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Second Address (ARCHIVED)

Do you have another address?

Yes

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Secondary Address (ARCHIVED)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home phone

Cell phone

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Day phone (ARCHIVED)

Emergency contact

Emergency Contact Name*

Relationship*

Emergency contact phone

Insurance

Insured or Self Pay*

Insured

Self-Pay

Primary insurance*

Policy ID number

Group Number

Policy Holder

If other than the patient

Policy holder birth date*

Month

Day

Year

Relationship to patient?

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Policy ID number (archive)

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Group number (archive)

Primary insurance address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Second Insurance

Yes

Do you have a secondary insurance plan?

Secondary insurance company

Secondary insurance ID number

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Secondary insurance ID number (archive)

Secondary insurance group number

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Secondary insurance group number (archive)

Secondary insurance policy holder

If other than the patient

Secondary insurance policy holder birth date

Month

Day

Year

Relationship to patient?

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Secondary insurance – claims billing address (ARCHIVED)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of injury while at work

MM slash DD slash YYYY

If Workers Comp

Do you have AHCCCS?

Yes

Employer

Occupation

Employment status

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Employer phone number (ARCHIVED)

Pharmacy

Pharmacy Name*

Pharmacy Cross Streets*

for example: Ft. Lowell & Campbell

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Pharmacy phone number (ARCHIVED)

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Pharmacy Address (ARCHIVED)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Secondary Pharmacy (ARCHIVED)

Yes

Do you have a second pharmacy we should keep on file?

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Pharmacy #2 name (ARCHIVED)

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Pharmacy #2 Cross Streets (ARCHIVED)

for example: Ft. Lowell & Campbell

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Pharmacy #2 address (ARCHIVED)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Pharmacy #2 phone number (ARCHIVED)

Demographics

Marital Status

Single

Married

Seperated

Divorced

Widowed

Spouse name

Race*

Asian

Black or African American

Declined to specify

Hispanic or Latino (all races)

Indian

Multi-racial

Native American

White or caucasian

Other

Ethnicity*

Unknown

Declined to specify

Hispanic or Latino

Not Hispanic or Latino

Other

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Preferred language (ARCHIVED)

English

Spanish

Other

Primary care provider*

Referring provider

Other providers involved in your care

Medical History

Conditions

Add all medical conditions that apply.

Medical Conditions	Actions

There are no Conditions.

Maximum number of conditions reached.

Surgery

Add all procedures you have had.

Procedure	Archived Procedure Date	Actions

There are no Procedures.

Maximum number of procedures reached.

Tobacco and Nicotine use

Have you ever used tobacco?*

Yes

Former

Tobacco use

Tobacco used

Daily use?

How many/much per day:

Age started

Age stopped

Have you ever used vape products?*

Yes

Former

Current vape status

Current user

Not a current user

Vaping without nicotine

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Age started

Please enter a number from 0 to 120.

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Age stopped

Please enter a number from 0 to 120.

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Vape used (ARCHIVED)

Vape used

Daily use?

How many/much per day:

Age started

Age stopped

Do you drink alcohol?*

Yes

Formerly

Frequency of alcohol use:

Medical

Family Conditions

Family conditions	Relation	Onset Age	Actions

There are no Conditions.

Maximum number of conditions reached.

Current Medications

Medication	Strength	Daily dose	Reason Prescribed	Actions

There are no Meds.

Maximum number of meds reached.

Allergies

Allergies	Note	Actions

There are no Allergies.

Maximum number of allergies reached.

Review of Systems

Items not selected will be assumed not currently occurring.

Have you fallen in the past year?

Yes

How many times have you fallen in the last year?

Please enter a number from 0 to 100.

Did the fall(s) result in injury?

Yes

Constitutional

Chilis

Fatigue

Fever

Malaise

Night Sweats

Weight Gain

Weight Loss

Other

Ear Nose Throat

Ear Drainage

Ear Pain

Eye Discharge

Eye Pain

Hearing Loss

Nasal Drainage

Sinus Pressure

Sore Throat

Visual Changes

Other

Cardiovascular

Chest Pain

Claudication (Leg Cramps)

Edema/Swelling

Palpitations

Raynaud’s Disease

Tests or procedure on arteries or veins in legs

Gastrointestinal

Abdominal Pain

Blood in Stools

Change in Stools

Constipation

Diarrhea

Heartburn

Loss of Appetite

Nausea

Vomiting

Neurological

Dizziness

Extremity Numbness

Extremity Weakness

Gait Disturbance

Headache

Memory Impairment

Seizures

Tremors

Integumentary

Breast discharge

Breast lump

Brittle hair

Brittle nails

Hair loss

Hirsutism (excessive body hair)

Hives

Pruritus (Itching)

Mole changes

Rash

Skin lesion

Respiratory

Cough

Known TB Exposure

Shortness of Breath

Wheezing

Immunologic

Contact Allergy

Environmental Allergies

Food Allergies

Seasonal Allergies

Psychiatric

Anxiety

Depression

Insomnia

Hematologic/Lymphatic

Easy Bleeding

Easy Bruising

Lymphadenopathy (Lymph Node Disease)

Metabolic/Endocrine

Cold Intolerance

Heat Intolerance

Polydipsia (Excessive Thirst)

Polyphagia (Escessive Hunger)

Musculoskeletal

Back Pain

Joint Pain

Joint Swelling

Muscle Weakness

Neck Pain

Genitourinary – FEMALE

Dysuria (Painful urination)

Hematuria (Blood in urine)

Polyuria (Genitourinary)*

Urinary Frequency**

Urinary Incontinence***

Urinary Retention****

Reproductive – FEMALE

Abnormal Pap

Dysmenorrhea (PainfulMenstruation)

Dyspareunia (Pain with sex)

Hot Flashes

Irregular Menses

Vaginal Discharge

Genitourinary – MALE

Dribbling

Dysuria (Painful urination)

Hematuria (Blood in urine)

Polyuria (Genitourinary)*

Slow Stream

Urinary Frequency**

Urinary Incontinence***

Urinary Retention****

Genitourinary Definitions
*Polyuria (Genitourinary): Excessive urination of more than 3 liters per day
**Urinary Frequency: The need to urinate many times during the day, at night (nocturia), or both but in normal or less-than- normal volumes.
***Urinary Incontinence: Involuntary leakage of urine.
****Urinary Retention: The inability to completely or partially empty the bladder.

Reproductive – MALE

Erectile Dysfunction

Penile Discharge

Sexual Dysfunction

Colonoscopy

Yes

Colonoscopy Date

Month and Year if known. Year only is ok.

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Archived Colonoscopy Date

Month

Date

Year

Cologuard

Yes

Cologuard Date

Month and Year if known. Year only is ok.

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Archived Cologuard Date

MM slash DD slash YYYY

Fecal Occult Blood Test

Yes

Fecal Occult Blood Test Date

Month and Year if known. Year only is ok.

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Archived Fecal Occult Blood Test Date

MM slash DD slash YYYY

Mammogram – FEMALE

Yes

Mammogram Date

Month and Year if known. Year only is ok.

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Archived Mammogram Date

Month

Date

Year

Other experiences not listed:

Request for Confidential Communication

HIPAA privacy rules give certain individuals the right to request confidential medical information. In that regard, you may select the method in which this confidential medical information is communicated. Also, ACS may need to communicate with you regarding your confidential medical information. Please select your preferred method of contact. If you would like to change your contact information in the future, please provide your request in writing to the address contained within the Privacy Practice Notice.

Approved Contacts

I give permission to disclose my confidential medical information to the following individuals:

Name

Relationship

Signature

Completing this documentation prior to your appointment does not establish a Patient-Physician Relationship. Information will be reviewed by your provider when you are seen.

Information Accuracy*

I attest the information provided is true and accurate.

I acknowledge I have read, signed and will abide by the Arizona Community Specialists Patient Payment and Financial Policies.

Electronic Prescriptions*

I give ACS permission to access my prescribed medications

ACS providers may prescribe medications electronically. By initialing, you give ACS permission to access your prescribed medications.

Notice of Privacy and HIPAA*

I acknowledge and consent to the Notice of Privacy and HIPAA.

I understand that under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Omnibus Rules of 2013, I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I acknowledge that I have received or had the opportunity to review the Notice of Privacy Practices from Arizona Community Specialists (“ACS”), which contains a more complete description of the uses and disclosures of my health information. I understand that ACS has the right to change its Notice of Privacy Practices from time to time and that I may contact ACS at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that ACS restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand ACS is not required to agree to my requested restrictions, but if ACS does agree then ACS is bound to abide by such restrictions.

ACS does not discriminate based on race, age, sex, sexual orientation, or ethnicity.

Finance Policy Acknowledgement

I have read and agree to the Payment Policy.

I agree to the Payment Policy and Assignment and Release of Information stated in the policy. I acknowledge my financial responsibility related to the services provided by Arizona Community Specialists.

Prescriptions and Narcotics Agreement

I have read and agree to the Prescriptions and Narcotics Agreement.

Medication History

I give Arizona Community Surgeons permission to obtain my medication history

Exam and Treatment

I hereby consent to the clinical exam and treatment to be provided.

Insurance

I give ACS permission to bill my insurance company (if applicable).

Arizona Community Services may bill my insurance for services and/or product(s) received on my behalf.

Electronic Signature*

I acknowledge use of E-Signature

My signature is acknowledgement of receipt of the policies and notices above. I understand I am responsible for reviewing and understanding the information provided by ACS and agree to comply. My signature confirms the information provided to ACS is true and accurate.

I ACKNOWLEDGE TYPING MY NAME BELOW CONSTITUTES AN ELECTRONIC SIGNATURE.

Patient Signature*

(or Parent/Guardian if patient is a minor)

Signature Date*

MM slash DD slash YYYY

Guarantor

Guarantor/Persons liable for bill, if other than the patient:

Guarantor Phone

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Guarantor Signature Date (ARCHIVED)

MM slash DD slash YYYY