Occupational Patient Intake Form

Pre-Employment | Work Injury Information

First Name*

Last Name*

Date of Birth*

SSN*

Gender*

Male
Female

Physical Address*

Street Address Address Line 2 City State ZIP Code

Is your mailing address different from your physical address?*

Yes
No

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone (if different)

Emergency Contact Name

Emergency Contact Home Phone*

Emergency Contact Cell Phone

Relationship to Contact*

Employer Phone*

Employer or Company applying for

Safety / Human Resource Contact

Employer Phone

Would you like to input work injury information?

Yes
No

Worker's Compensation Company*

Adjuster Name*

Date of Injury*

Was the initial injury reported?*

Yes
No

Claim Number*

Brief explanation of injury:*

Do you have previous problems related to current injury?*

Yes
No

Are you currently taking medication?*

Yes
No

Please list your current medications*

Do you have any medication allergies?*

Yes
No

Please list the medications and what happens when you take them*

Do you have a current medical diagnosis?*

Yes
No

What is your current medical diagnosis?*

Do you have any surgical history?*

Yes
No

What is your surgical history?*

Do you have insurance information?*

Yes
No

In the case that you do not have insurance, you will be set to self-pay and will be responsible for all services provided.

In the case that this visit is denied by Workers Compensation, we will need your private insurance information. Your private insurance will not be billed unless this claim has been denied, as a work injury.

Primary Insurance*

Name of Insured*

Birth Date of Insured*

Relationship to Patient*

SSN of Insured*

ID Number*

Group Number*

The information that I have provided is true and correct to the best of my knowledge.

Release of information, treatment, privacy rights, and messages

Authorization for Treatment*

I hereby authorize Occupational Health providers, assistants, and associates to administer exams, treatment, or procedures deemed necessary or advisable for my care. I also acknowledge that no guarantees have been made to me as to the outcome of my treatment or condition.

Authorization to obtain and/ or release information*

I hereby authorize and release copies of my medical records to Minidoka Medical Center/Occupational Health, employer, or family physician. This may include pre-employment physical, drug screening, lab studies, x rays, surgical notes, previous medical records, etc. These records will not be obtained or released unless it is medically necessary for your treatment or billing.

Privacy Practices Acknowledgement*

I have received/or declined copy of the NOTICE of Privacy Practices and I have been provided an opportunity to review the entire document.

Use of answering machine and/or voicemail messaging:*

I hereby consent to the use of my answering machine and/or voicemail for the purpose of relaying important information regarding my treatment or care, including, but no limited to confirmation of appointments, changes in medication, results of lab tests, special instructions for testing procedures. I also consent to members of my family receiving this information in my absence. This consent will remain in effect until I rescind the consent in writing.

Name of Family Physician*

Signature

Phone*

Today's Date*

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Pre-Employment | Work Injury Information

Release of information, treatment, privacy rights, and messages

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OUR ADDRESS

1224 8th Street
Rupert, Idaho
83350

(208) 436-0481

Notice of Privacy Practice
Aviso de Prácticas de Privacidad
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LATEST NEWS

OUR ADDRESS

1224 8th Street
Rupert, Idaho
83350

(208) 434-8340

Notice of Privacy Practice
Aviso de Prácticas de Privacidad

OUR ADDRESS

1224 8th Street
Rupert, Idaho
83350

(208) 436-0481

Notice of Privacy Practice
Aviso de Prácticas de Privacidad