INTERNAL MEDICINE OF THE TWIN CITIES
MEDICAL REGISTRATION FORM
PATIENT INFORMATION
Patient’s last name:
Middle:
First:
Marital status (circle one)
Single / Mar / Div / Sep / Wid
Birth date:
/
Age:
Sex:
M
/
Social Security #:
Primary phone #:
F
Alternate phone #:
Street address:
City:
Mailing address (if different than street address):
State:
Occupation:
ZIP Code:
Employer:
Employer phone #:
(
)
Email Address:
Referred to Clinic by:
IN CASE OF EMERGENCY
Name:
Relationship to patient:
Home phone no.:
Work phone no.:
(
(
)
)
INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Person responsible for bill:
Birth date:
/
Is this person a patient here?
Occupation:
Home phone no.:
/
 Yes
Employer:
Address (if different):
(
 No
Employer address:
Employer phone no.:
(
Is this patient covered by
insurance?
)
 Yes
)
 No
Name of primary insurance
Subscriber’s name:
Subscriber’s S.S. no.:
Birth date:
/
Patient’s relationship to subscriber:
 Self
Name of secondary insurance (if
applicable):
Patient’s relationship to subscriber:
 Spouse
Group no.:
 Child
 Spouse
 Other
Group no.:
 Child
Co-payment:
$
Subscriber’s name:
 Self
Policy no.:
/
Policy no.:
 Other
INSURANCE ASSIGNMENT AND RELEASE
I acknowledge that payment is due at the time of treatment. I accept full financial responsibility for all charges for
services provided to me or to the patient for whom I have legal responsibility. I certify that I have coverage with
the above named insurance companies and assign payment to Internal Medicine of the Twin Cities. I
understand that filing a claim with my insurance company does not relieve me from my responsibility for the
payment of all charges for services rendered. I hereby authorize this clinic to release all information necessary to
secure with payment of benefits. I understand that it is my responsibility to keep all insurance information current.
I authorize the use of this signature on all insurance submissions.
Responsible Party Signature
Page 1
Relationship to Patient
Date
INTERNAL MEDICINE OF THE TWIN CITIES
HEALTH HISTORY
Name:
Birth Date:
Date:
Please check all symptoms you currently have or have had in the past year.
Chills
General
Gastrointestinal
Poor appetite
Eye / Ear / Nose / Throat
Bleeding gums
Depression
Bowel changes
Blurred vision
Erection problems
Dizziness
Constipation
Difficulty swallowing
Lump in testicles
Fainting
Diarrhea
Double vision
Penis discharge
Fever
Excessive hunger
Earache
Sore on penis
Forgetfulness
Excessive thirst
Ear drainage
Other:
Headache
Excess gas
Hay fever
Loss of Sleep
Hemorrhoids
Hoarseness
Women only
Weight loss
Indigestion
Loss of hearing
Abnormal pap
Nervousness
Numbness
Nausea
Rectal bleeding
Nosebleeds
Persistent cough
Irregular bleeding
Breast lump
Stomach pain
Ringing in ears
Menstrual pain
Muscle / Bones
Vomiting
Sinus problems
Nipple discharge
Pain, weakness
Vomiting blood
Vision-flashes
Painful intercourse
Or numbness in:
Unusual weight loss
Vision-halos
Vaginal discharge
Back, hips
Cardiovascular
Skin
Legs, knees, feet
Chest pain
Bruise easily
Neck, shoulders
High blood pressure
Hives
Irregular heart beat
Itching
Date of last PAP:
Genitourinary
Blood in urine
Low blood pressure
Poor circulation
Changes in moles
Rash
Have you had a
Frequency
Rapid heart beat
Scar
Mammogram?
Incontinence
Swelling of ankles
Sore that won’t heal
Pregnant?
Painful urination
Varicose veins
Abnormal growth
Conditions that you have had in the past year
# Of children?
Alcoholism
Chemical dependency
High cholesterol
Prostate problem
Anemia
Chicken pox
HIV positive
Psychiatric care
Anorexia
Diabetes
Kidney disease
Rheumatic fever
Appendicitis
Emphysema
Liver disease
Scarlet fever
Arthritis
Epilepsy
Measles
Stroke
Asthma
Bleeding disorder
Glaucoma
Goiter
Migraine headaches
Miscarriage
Suicide attempt
Thyroid problems
Breast lump
Gout
Mononucleosis
Tonsillitis
Bronchitis
Heart disease
Multiple sclerosis
Tuberculosis
Bulimia
Hepatitis
Mumps
Typhoid fever
Cancer
Hernia
Pacemaker
Ulcers
Herpes
Pneumonia
Venereal disease
Arms, hands
Cataracts
Please list ALL allergies:
Page 2
Men Only
Breast lump
Other:
Date of last period:
INTERNAL MEDICINE OF THE TWIN CITIES
HEALTH HISTORY
Name:
Birth Date:
Date:
Family History
Relation
Age
State
of
Health
Age of
death
Cause of
Death
Check if any relatives have the following:
Disease
Mother
Arthritis, gout
Father
Asthma, Hay fever
Brothers
Cancer
Relationship to you
Chemical dependency
Diabetes
Sisters
Heart Disease, stroke
High blood pressure
Kidney disease
Tuberculosis
Other
Year
Hospital
Hospitalizations and/or Surgeries
Reason for hospitalization and outcome
Pregnancy History
Year
Sex
Complications if any
Health Habits
Type
Frequency
Occupational habits/exposure
Stress
Caffeine
Heavy Lifting
Tobacco
Chemicals or hazardous substances
Drugs
Other:
Other:
I certify that the above information is correct to the best of my knowledge. I will not hold doctors or any members of his staff
responsible for any errors or omissions that I may have made in completing this form.
____________________________________
Signature of patient or responsible party
Page 3
___________________
Date
_________________________________
Reviewed by
INTERNAL MEDICINE OF THE TWIN CITIES
PATIENT COMMUNICATION PREFERENCES FORM
I wish to be contacted in the following manner:
(Please place a check by all that apply to you)
 Home Telephone # ____________________________________________
o O.K. to leave message with detailed information, or
o Leave message with call back number only, or
o Do not use home phone
 Cellular Telephone # ______________________________________________________
o Use as primary number for contact, or
o Use only if unable to contact at home
 Work Telephone # ________________________________________________________
o Use as primary number for contact
o O.K. to leave message with call back number, or
o Use this number for emergency only
 Written Communication
o O.K. to mail to my home address
o O.K. to mail to my work address
o O.K. to fax to this number _______________________
If an emergency should occur and I can not be reached by any of the above selected methods
please contact the person below:
Name:____________________________________________________________________________________
Relationship to Patient: ______________________________________________________________________
Home Telephone #:_________________________________________ Cell Telephone #: ________________
Work Telephone #: ______________________________________; Ext: ______________________________
____________________________________________
Signature of patient or personal representative
________________________________________
Date
____________________________________________ __________________________________________
Please print name of patient or representative
Relationship to patient
Page 4
Authorization to Release Medical Records
Name: _________________________________ Date of Birth: ________________________
Address: _____________________________________________________________________
Social Security Number: _________________________________________

I hereby authorize and request ______________________________________ to release my medical
records to:
Internal Medicine of the Twin Cities
Amin El-Malah, MD & Khaled Shafiei, MD
3510 Medical Park Drive Suite 9
Monroe, LA 71203
Phone (318) 388-6050 Fax (318) 388-2024

Release all medical records in your possession concerning my illness and or treatment during the period
from __________to __________.
___________________________
Patient and or Guardian Signature
____________________________
Date
___________________________
Relationship to Patient if Guardian
____________________________
Date
____________________________
Witness Signature
____________________________
Date
Page 5
Internal Medicine of the Twin Cities
Prescription Policy and Agreement
All patients are required to sign this Prescription Policy and Agreement. Failure to adhere to the rules and
regulations of this agreement could result in the dismissal of care. I agree to the following in conjunction with my
pain management treatment under the supervision of the physicians and/or staff designated by the physicians.
1. Medication refill appointments must be scheduled at least 7-10 days in advance. It is the patient’s
responsibility to keep track of the amount of medication remaining and to schedule appointments
appropriately.
2. Take medications as prescribed. Early refills will NOT be given. If you use up all your medications earlier
than the scheduled refill date, the remaining days will be endured with NO medications.
3. All narcotics must come from one physician. You must notify our doctors of any narcotic medication
orders made by other physicians while under the care of IMTC. Refills of controlled substance
medications will be made only during regular business hours, Monday through Friday, in person, once
every 30 days during a scheduled office visit. Refills will NOT be made at night, on holidays, weekends or
by phone.
4. Refills will not be made if a patient “runs out early” or “loses a prescription” or spills the medications for
any other reason.
5. Patients are responsible for taking the medication in the dose prescribed and for keeping track of the
amount remaining.
6. Refills will not be made as an “emergency” such as a Friday afternoon because “suddenly realized the
prescription is about to run out.”
7. Calls should be made at least seventy-hours (72) hours ahead if assistance is needed with a controlled
substance medication prescription.
8. All medication is to be kept in a safe place, especially away from children. They may hazardous of lethal
should they be inadvertently taken by any other person other than for whom they were prescribed.
9. All medications must be obtained at ONE designated pharmacy.
10. The prescribing physician has complete liberty to discuss fully all diagnostic and treatment details with the
dispensing pharmacy for purposes of maintaining accountability.
11. Urine toxicology screening may be done at anytime. Failure to comply with drug screening is reasonable
cause for discontinuing controlled medicine. Charges not covered by Insurance will be billed to patient.
12. Prescription altering is Federal offense and we will report any violations or suspicions of such to the
proper authorities.
13. Should prescriptions need to be changed prior to the “due date” all unused medication must be brought
to our office prior to receiving a new prescription.
14. IMTC and/or designated staff reserve the right to communicate with previous or present physicians that
have cared for you and/or your previous or present insurance carriers.
Initial______________
Page 6
Consent for Chronic Opioid Therapy
I am fully aware that Internal Medicine of the Twin Cities and/or officially designated representative of IMTC is
prescribing opioid medicines, sometime called narcotic analgesics, as part of my pain therapy. Internal Medicine I
attest to the following statements:
1. I am not currently abusing illicit or prescription drugs, and I am not undergoing treatment for
substance dependence or abuse
2. I have never been involved in the sale, diversion or transport of controlled substances. I
understand that the authorities will be notified if these activities are suspected.
3. I will obtain all prescriptions for narcotic analgesics from ONE pharmacy on record and reveal all
other medications that I am taking.
4. I give my permission to allow IMTC staff and physicians to discuss my case with my other current
and previous physicians and pharmacists.
5. I agree to take my medications ONLY AS PRESCRIBED by my physician.
6. I agree to follow the advice of the physicians/ nurse practitioners of IMTC regarding the
discontinuation of controlled substances as they advise.
7. I understand that IMTC reserves the right to order urine drug screens at any time and I will
comply with such request. I understand that I will be responsible for the cost of these drug
screens in the event that my insurance does not cover the charges.
8. I understand that IMTC will make NO allowance for lost prescriptions or medications. My
medication is my responsibility to protect.
9. I understand that IMTC reserves the right to Stop prescribed controlled medications or release
me from care, should any violations of this agreement occur.
10. Through the chronic administration or narcotic medications may not necessarily impair mental
function, I understand that operating potentially hazardous devices, such as vehicles or
machinery, while taking narcotics could place others or myself at risk. I will not perform any
hazardous task while taking narcotic medications. Because these medications can impair or
decrease mental function, I will not make any important decisions or commitments without
consulting responsible and trusted advisors while taking narcotics.
11. I understand that I may be called between scheduled appointments to bring my medications
prescribed by Internal Medicine of the Twin Cities in for a “pill count.”
12. (FEMALES ONLY) I certify that I am not pregnant. If I plan to become pregnant or believe that I
have become pregnant while taking this plan medicine, I will immediately call my obstetric doctor
and this office to inform them. I am aware that should I carry a baby to delivery while taking these
medications: the baby will become physically dependent upon opioids. I am aware that use of
opioids is generally not associated with a risk of birth defects. However, birth defects can occur
whether or not the mother is on medicines and there is always the possibility that my child will
have a birth defect while I am taking an opioid.
13. (MALES ONLY) I am aware that chronic opioid use has been associated with low testosterone
levels in males. This may affect my mood, stamina, sexual desire, and physical and sexual
performance. I understand that my doctor may check my blood to see if my testosterone level is
normal.
Print Name: ______________________________
Signature: ________________________________ Date: ____________
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Internal Medicine of the Twin Cities
Notice of Health Information Privacy Practice
THIS NOTICE DECRIEES HOW INFORMATION ABOUT YOUR HEALTH MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY; THIS NOTICE
OF HEALTH INFORMATION PRIVACY PRACTICES IS EFFECTIVE APRIL 14, 2003.
UNDERSTANDING YOUR HEALTH RECORD AND INFORMATION
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this
record contains your symptoms, examination and your test results, diagnosis, treatment and a plan for future care
of treatment. This information is often referred to means of communication among the many health professionals
who may contribute to your care, the means by which you or a third party payer can verify that services billed
were actually provided, and a tool with which we can assess and continually work to improve the care we render
and the outcomes we achieve.
Understanding what is in your record and how your health information is used helps you to endure its accuracy,
better understand who, what, where and why others may access your health information, and make more
informed decisions when authorizing disclosures to others.
YOUR HEALTH INFORMATION RIGHTS
Although your health record is the physical property of the healthcare practitioner or facility that complied it, the
information belongs to you. You have the right to:

Request a restriction on certain uses and disclosures of your information as provided by 45 CFR
164.522, although this entity is not required to agree to any requested restriction

Receive confidential communications of protected health information as provided by 45 CFR 164.522

Obtain a paper copy of the notice of information practice upon request

Inspect and obtain a copy of your health information as provided for in 45 CFR 164.526

Amend your health record as provided in 45 CFR 164.526

Obtain and accounting of disclosures of your health information as provided in 45 CFR 164.528

Request communications of your health information by alternative means or at alternative locations

Revoke your authorization to use or disclose health information except to the extent that action has
already been taken
OUR RESPONSIBLILITES
This organization is required by law to:

Maintain the privacy of your health information

Provide you with a notice as to our legal duties and privacy practices with respect to information we
collect and maintain about you

Abide be the terms of this notice

Notify you if we are unable to agree to a requested restriction

Accommodate reasonable requests you may have to communicate health information by alternative
means or at alternative locations
We reserve the right to change our practice and to make the new provisions effective for all protected health
information we maintain.
We will not use or disclose your health information with your authorization, except as described in this notice.
Page 8
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events
with respect to food, supplements, product and product defects, or post marketing surveillance information to
enable product recalls, repairs or replacement.
Workers compensations: We may disclose health information to the extent authorized by and to the extent
necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public health: As required by law, we may disclose your health information to public health or legal authorizes
charged with preventing or controlling recalls, repairs or replacement.
Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or
agents thereof health information necessary for your health and the health and safety of other individuals.
Law enforcement: We may disclose health information for law enforcement purposes as required by law or in
response to valid subpoena.
Oversight: Federal law makes provisions for your health information to be released to an appropriate health
oversight agency, public health authority or attorney, provided that a work force member or business associate
believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical
standards and are potentially endangering one or more patients, workers, or public.
Any other uses and disclosures will be made only with your written authorization. You may revoke such
authorization, if given, as provided by 45 CFR 508(b)(5).
I, (patient name)_____________________________________, acknowledge receipt of this Notice of Health
Information Privacy Practices.
I,___________________________, certify that I have made a good faith effort to obtain written acknowledgement
of receipt of this Notice of Health Information Privacy Practices, from patient__________________________, but
the acknowledgement was not obtained because:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________
__________________________________________________________________________________
This_____________ day of ________________ 20___.
THIS DOCUMENT MUST REMAIN IN THE PATIENTS CHART AT ALL TIMES.
Page 9
FOR MORE INFORMATION TO REPORT A PROBLEM
If you have questions and would like additional information, please contact our designated Privacy Official:
Linda Anders
Office Manger
3510 Medical Park Dr. Suite 9
Monroe, LA 71203
Phone (318)388-6050
Fax: (318) 388-3204
If you believe your privacy rights have been violated, you can file a complaint with the director of health
information management either orally or in writing, or you may file with the Secretary of Health and Human
Services. There will be no retaliation for filing a complaint.
EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH OPERATION:
We will use your health information for treatment.
For example: Information obtained by a nurse, physician, or other member of your healthcare team will be
recorded in your record and used to determine the course of treatment that should work best for you. Your
physician will document in your record his or her expectations of the members of your healthcare team. Members
of your healthcare team will then record the actions they took and their observations. In that way, the physician
will know how you are responding to treatment.
We will use your health information for payment.
For example: A bill may be sent to you or a third party payer. The information on a or accompanying the bill may
include information that identifies you, as well as your diagnosis, procedures and supplies used.
We will use your health information for regular health operations.
For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality
improvement team may use information in your health information to our business associates so that they can
perform the job we have asked them to do and bill you or your third party payer for services rendered. To protect
your health information, we require the business associated to appropriately safeguard.
Business associate: There are some services provided to our organization through contact with business
associates.
Examples include: Physician services in the emergency department and radiology, certain lab test. When their
services are contracted, we may disclose your health information to our business associates so that they can
perform the job we have asked them to do and bull you or your third party payer for services rendered. To protect
your health information, we require the business associated to appropriately safeguard your information.
Page 11
Notification: We may use or disclose information to notify and assist in notifying a family member, personal
representative, or another person responsible for your care, your location and general condition.
Communication with family: Health professionals, using their best judgment may disclose to a family member,
other relative, close personal friend or any other person you identify, health information relevant to that person’s
involvement in your case or payment related to your care.
Page10
Research: We may disclose information to researchers when their research has been approved by an
institutional review board that has reviewed the research proposal and established protocols to ensure the privacy
of your health information.
Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry
out their duties.
Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ
procurement organizations or other entities engaged in the procurement, banking or transplantation of organs for
the purpose of tissue donation and transplant.
Marketing: We may contact you to provide appointment reminders of information about treatment alternatives or
other health benefits and services that may be of interest to you.
AUTHORIZATION FOR DISCLOURE OF PATIENT HEALTH INFORMATION
1. I,________________________, hereby authorize the Internal Medicine of the Twin Cities to disclose the
following protected health information to:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________
2. The specific information subject to this authorization is:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________
3. The protected health information is being used or disclosed for the following purposes:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________
4. This authorization shall be in force and effect until _____________________ at which time this
authorization to disclose this protected health information expires.
5. I understand that I have the right to revoke this authorization, in writing, at any time by sending written
notification to this Health Care Provider. I understand that a revocation is not effective:
a. To the extent that this health care provider has relied on the use or disclosure of the
protected health information: or
b. If the authorization is obtained as a condition of obtaining insurance coverage, if some other
law or the policy itself provides the insurer with the right to contest a claim under the policy.
6. I understand that information used or disclosed pursuant to this authorization may be subject to
redisclousre by the recipient and may no longer be protected by federal or state law.
7. I understand that this health care provider may not condition my treatment, payment, enrollment in a
health plan, or eligibility for benefits (if applicable) on whether I provide this authorization for the
requested use or disclosure.
Page 11
8. I understand that I have the right to:
a. Inspect or copy the protected health information to be used or disclosed as permitted under
federal law, or state law to the extent the state law provides greater access rights; and
b. Refuse to sign the authorization.
________________________________
Signature of Patient or Representative
__________________________________
Printed Name of Patient or Representative
Page12
_______________
Date
_________________________________
Description of Representative’s Authority