www.hughston.com/pdf/patient_forms.pdf

MEDICAL HISTORY QUESTIONNAIRE Patient Name _________________________________________________________ Chart# ________________________ Date of birth ______________________ Age ___________ Sex ___________ Height ___________ Weight ___________ (For office use only: BP ______________ Pulse ______________) Who referred you for this visit; if not referred, please indicate ___________________________________________________ Past Medical History Do you have, or have you had, any of the following: (PLEASE CIRCLE)
Diabetes High blood pressure Heart condition Seizure Sleep apnea Ulcer Cancer Blood or bleeding disorder
Phlebitis or blood clots Stroke Asthma Emphysema Complication of anesthesia Kidney stone List other medical conditions and/or illnesses not mentioned above _____________________________________________ ___________________________________________________________________________________________________ List reasons for hospitalizations and/or surgeries with dates and any complications _________________________________ ___________________________________________________________________________________________________ List any significant injuries you have sustained ______________________________________________________________ List current medications ________________________________________________________________________________ ___________________________________________________________________________________________________ List any Drug Allergies _________________________________________________________ / Latex Allergy? Yes or No
Family History (if deceased, please provide age and cause) Age(s) and overall health of parents ______________________________________________________________________ Age(s) and overall health of sibling(s) _____________________________________________________________________ List any significant family health problems __________________________________________________________________ Social History Marital status ____________ Education (Years/Degrees) _____________________________________________________ Alcohol use (type/amount) ________________________ Tobacco use (amount/years used) _________________________ Employer __________________________________________________ Occupation ______________________________ Review of Systems (Circle positive symptoms and describe and/or add others, if needed.) Constitutional: Fever, weight
gain/loss, loss of appetite Eyes: Double vision, blurring,
difficulty seeing ENT: Deafness, sinusitis,
hoarseness, vertigo Cardiovascular: Chest pain,
palpitations, irregular/rapid
heartbeat, murmur Respiratory: Shortness of breath,
wheezing, spitting blood, chronic
cough Digestive: Abdominal pain,
constipation, diarrhea, bleeding Urologic: Pain when urinating,
hesitancy, bleeding, incontinence Skin: Rashes, lesions that do not
heal, changes in moles Gynecologic: Breast masses, pain,
discharge, problems
Date of last gynecologic check-up
____________________________
Date of last pap smear
____________________________ Neurologic: Seizures, loss of
balance/coordination, paralysis,
weakness, loss of memory Psychiatric: Depression, anxiety,
hallucinations, sleep disturbances Endocrine: Excessive thirst,
excessive urination, heat/cold
intolerance Blood and Lymph: Anemia,
bleeding tendencies, swollen nodes Allergic and Immunologic: Hives,
eczema, itching Musculoskeletal: Stiffness, joint
pain/deformity, muscle wasting,
spine pain radiating to arm/leg


Other: _____________________________________________________________________________________________ ___________________________________________________________________________________________________ __________________________________________________________ ______________________
Patient Signature Date __________________________________________________________ ______________________
Physician Signature Date
HIPAA NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you may get access to this
information. Please review it carefully.

Hughston Clinic is dedicated to protecting your medical information. We are required by law to maintain the privacy of
protected information and to provide you with this Notice of our legal duties and privacy practices with respect to protected
health information. Hughston Clinic is required by law to abide by the terms of this Notice.

How your medical information will be used and disclosed:
We will use your medical information as part of rendering patient care. For example, the doctor or nurse treating you, by the
business office to process your payment for the services rendered and by administrative personnel reviewing the quality of the
care you receive may use your medical information.

We may also use and/or disclose your information in accordance with federal and state law without your consent for the
following purposes:
• Appointment Reminders -May contact you to provide appointment reminders • Treatment Information - Other alternative treatments or health-related services that may be of interest to you • Law Enforcement - May disclose your information as required during as investigation • Legal Proceedings - May disclose your information in the course if certain judicial or administrative proceedings • Public Safety- May disclose your information to prevent or lessen serious threat to the health or safety to the public • Military Activity and National Security- May disclose information to military command for their military records or other federal officials conducting national security and intelligence activities for protective services for the President
• Worker’s Compensation- May disclose information as authorized to worker’s compensation or similar programs • Inmates- May disclose information to the correctional facility or law enforcement official for your proper care • Abuse or Neglect-May disclose information when it concerns abuse, neglect or violence in accordance to federal or state law • Coroner, Medical Examiner, or Funeral Director- May disclose information for identification of a body or determine cause of death
• Food and Drug Administration- May disclose information to report adverse events, product recalls, to make repairs or replacements
• Research- May disclose information for certain research purposes if an Institutional Review Board that has reviewed the research proposal and established protocols to ensure the privacy of your information {GA Code Ann.§ 31-7-6(b)}
• Disclosure to Department of Health and Human Services- May disclose information for public health purposes to help control disease, injury, or disability, also to a person who may have been exposed to a communicable disease or at risk of
contacting or spreading a disease or condition
• Others Involved in Your Healthcare- May disclose information to a family member, other relatives, close personal friends or other representative you authorize when medical information is directly relevant to that person’s involvement in your care
• Health Oversight Activities- May disclose information for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee health care systems,
government benefit programs, and other government regulatory programs and civil rights law.
• Disaster Relief- May disclose information to a public entity, such as the American Red Cross, for purpose of coordinating with that entity to assist in disaster relief efforts
• Facility Directory- Unless you object, we will use and disclose in our facility directory your name, and the location at which you are receiving care. This information will be disclosed only when someone calls and ask for you by name
• Business Associates- May disclose information to a business associate that we have a contract with to provide services on our behalf. We require our business associates to appropriately safeguard the health information of our patients

AUTHORIZATIONS:

We will not use or disclose your medical information for any purpose without your written authorization. Once given, you may
revoke your authorization in writing at any time. To request a Revocation of Authorization form, you may contact:
Your Personal Provider (Physician) Hughston Clinic 6262 Veteran’s Parkway Columbus, GA 31908 (706)324-6661/1-800-331-2910
HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
CAREFULLY.  
Summary: 
By law, we are required to provide you with our Notice of Privacy Practices (NPP).  
This notice describes how your medical information may be used and disclosed by us.  
It also tells you how you can obtain access to this information. 
As a patient, you have the following rights:  1.  The right to inspect and copy your information. 
2.  The right to request corrections to your information. 
3.  The right to request that your information be restricted. 
4.  The right to request confidential communications. 
5.  The right to a report of disclosures of your information. 
6.  The right to a paper copy of this Notice. 
7.  The right to file a complaint if you feel your privacy has been violated.  We want to assure you that your medical/protected health information is secure with 
us.  This Notice contains information about how we will insure that your information 
remains private. 
  Acknowledgement of Notice of Privacy Practices  I  hereby  acknowledge  that  I  have  received  a  copy  of  The  Hughston  Clinic’s  NOTICE 
OF  PRIVACY  PRACTICES.    I  understand  that  if  I  have  questions  or  complaints 
regarding  my  privacy  rights,  that  I  may  contact  the  person  named  as  the  Privacy 
Officer.  I  further  understand  that  The  Hughston  Clinic  will  offer  me  updates  to  this 
NOTICE  OF  PRIVACY  PRACTICES,  should  it  be  amended,  modified  or  changed  in 
any way.  
  Patient or Representative Name (Please Print) 
 
______________________________________________   ________________________ 
Patient or Representative Signature                                        Date    Patient refused to sign            Patient was unable to sign because‐                                                            _____________________________________   
                                                          Documented by_______________________ 

Affix Patient Label
AUTHORIZED PATIENT NOTIFICATION LIST (Required of HIPAA) Health Insurance Portability and Accountability
I authorize all Hughston Clinic Physicians and/or whomsoever he/she may designate
as his/her professional representative/assistant to discuss any aspect of my orthopedic
care, to include: appointments, tests, test results, surgical procedures, prescriptions,
and any other pertinent information pertaining to my care with the following
designated people:
___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ This document will be a part of your permanent record. In the event that any of the
selected representatives that you have designated change, it will be necessary to
update our records with a written notification. You will need to state who you would
like to have removed from or added to the Authorized Notification List.


_____________________________________________ __________________ PATIENT/OTHER PERSON AUTHORIZED TO SIGN DATE
______________________________________________ __________________ RELATION TO ABOVE SIGNATURE DATE
______________________________________________ __________________ WITNESS SIGNATURE DATE
FINANCIAL POLICY

Thank you for choosing The Hughston Clinic, PC as your Orthopedic specialty healthcare provider. We
are committed to providing you and your family with the best available medical care. In our ongoing
process to make sure that all your medical needs are met, our staff will be available to discuss our fees
and this policy with you. The services you have elected to participate in imply a financial responsibility
on your part.

We ask that all responsible parties read and sign our financial policy as well as complete the patient
information forms prior to seeing the physician.

Payments for all services will be due at the time services are rendered. In order to serve you better, we
accept cash, check, Visa, MasterCard, Discover, and American Express. As a courtesy to you, we will
verify your coverage and bill your insurance carrier on your behalf; however, you are ultimately
responsible for the entire bill. As the responsible party, please understand:

(PLEASE INITIAL THE FOLLOWING)

_____ 1. Your insurance policy is a contract between you, your employer (if applicable), and the
insurance company. We are not a party to that contract. Our relationship is with you, not your insurance
company. We will not become involved in disputes between you and your insurer regarding deductibles,
co-payments, covered charges, secondary insurance and “usual and customary” charge. As your medical
provider, we will only supply factual information to facilitate claim processing.

_____ 2. Fees for services, which include unpaid balances, deductibles and co-payments and in some
cases coinsurance, are due at the time of service. Returned checks and unpaid balances may be subject to
collection placement and collection fees.

_____ 3. All charges are your responsibility whether your insurance company pays or does not pay. If
your insurance carrier does not remit payment within sixty days, the balance may be due in full from you.
If any payment is made directly to you for services billed by The Hughston Clinic, you recognize an
obligation to promptly remit payment to The Hughston Clinic, PC.

_____ 4. I understand and agree that if I fail to make any of the payments for which I am responsible in a
timely manner, after such default and upon referral to a collection agency or attorney by The Hughston
Clinic, PC, I will be responsible for all costs of collecting monies owed, including collection agency fees.

_____ 5. The above does not apply for those patients that are considered Workers’ Compensation.
However, be advised that as a compensation patient you may be held responsible for charges in the event
that your claim is denied or not paid or determined not to be work related.


_____6. Our practice utilizes the services of Assistant Surgeons/Physician Assistants for medical services
including surgical procedures. As with the other professional services we will bill your insurance for
these services; however, should your insurance not cover the charges you may be held ultimately
responsible.

_____7. The completion of disability and/or FMLA forms are not billable/reimbursable by insurance
carriers, therefore fees are your responsibility for payment. Hughston Clinic fees related to completion of
these documents are expected to be paid upon presentation of forms for completion.

We understand that financial problems may affect timely payment, so we encourage you to communicate
any such problems to us, so that we may assist you in keeping your account in good standing. Our
financial counselor is available to assist you or answer any questions you may have.

I UNDERSTAND THE ABOVE INFORMATION AND WILL BE RESPONSIBLE FOR THE
PATIENT LISTED BELOW

Printed Name of Patient: __________________________

______________________________________________ _____________________ Signature of Patient or Responsible Party Date
_____________________________________________
Relationship if other than the patient

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