Family
Practice
Application
Cassandra Dingus, MSN, FNP
Donald Dingus, MD
Across The Tracks Healthcare
Attention: To be considered for acceptance into the practice as a family care patient,
this packet must be filled out in its entirety. After solicitation of your previous medical
records, the physicians will review your application. Your request will then either be
confirmed or denied, and you will be notified of the result. Please note, that returning
the completed forms does NOT establish a patient/doctor relationship, nor does it
make one of our providers your Primary Care Physician. If you have any further
questions, please contact our office at 276-523-4890 or visit our website at
www.acrossthetrackshealthcare.weebly.com.
Across The Tracks Healthcare
205 East 19th Street North
Big Stone Gap, VA 24219
Phone: (276) 523-4890 Fax: (276) 523-4541
www.acrossthetrackshealthcare.weebly.com
Donald E. Dingus II, MD Cassandra R. Dingus, MSN, FNP
PATIENT INFORMATION
Date: ___________
Name: ____________________________________________________________________________________________________
Last
First
Middle
Suffix
Birth/Maiden
DOB: ___________________________ Sex: Male Female SSN: ____________________________ Marital Status: ____________
Home Phone: ___________________ Cell Phone: _________________ Email: ________________________________________
Mailing Address: ____________________________________________________________________________________________
Street
City
State
Zip
Physical Address:____________________________________________________________________________________________
Street
City
State
Zip
Occupation: __________________ Employer: _____________________________ Work Phone: ________________________
Other Family Members Seen Here: _____________________________________________________________________________
INSURANCE INFORMATION
Person Responsible for Bill: _____________________ Relationship: ___________________ Phone: ______________________
Address: _____________________________________________________________ Is this person a patient here? Yes No
Street
City
State
Zip
Occupation: ____________________ Employer: ____________________________ Work Phone: _______________________
Employer’s Address: _________________________________________________________________________________________
Street
City
State
Zip
Primary Insurance: _____________________ Group #: __________________ Policy #: _______________________________
Subscriber’s Name: _______________________ Subscriber DOB: _________________ Subscriber SSN: _________________
Secondary Insurance (if applicable): __________________ Group #: _________________ Policy #: _______________________
IN CASE OF EMERGENCY
Contact Person: ___________________________ Relationship: __________________ Phone: _______________________
Contact Person: ___________________________ Relationship: __________________ Phone: _______________________
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the
physician/practitioner. I understand that I am financially responsible for any balance. I also authorize Across the Tracks
Healthcare or insurance company to release any information required to process my claims.
_______________________________________________________
Patient / Guardian Signature
_____________________________________
Date / Time
Form 005 | 9/2014
Across The Tracks Healthcare
205 East 19th Street North
Big Stone Gap, VA 24219
Phone: (276) 523-4890 Fax: (276) 523-4541
www.acrossthetrackshealthcare.weebly.com
Donald E. Dingus II, MD Cassandra R. Dingus, MSN, FNP
Why are you here today? _____________________________________________________________________________
Are you a new or established patient?
__________NEW
__________ESTABLISHED
Is this an acute (new)____________ or _____________ chronic (old) medical problem?
When did this problem occur/start (date): _____/_____/_____
Are you currently seeing another physician/practitioner? _________YES __________NO
Name of current provider_____________________________________________________
What is your height? _____ft ______in
what is your weight? __________lbs.
Do you smoke? ___________ If yes, how much daily and for how long ___________________/____________________
Any known ALLERGIES to medications? (If so please list) ___________________________________________________
Please list the type of reaction you have to any medications you are ALLERGIC to: ______________________________
__________________________________________________________________________________________________
Any known food, chemical or environmental ALLERGIES? (If yes, please list and the type of reaction you have)
__________________________________________________________________________________________________
List all medications you are taking (over the counter and prescription):
______________________________________
____________________________________________
______________________________________
____________________________________________
_______________________________________
____________________________________________
_______________________________________
_____________________________________________
Which pharmacy do you use? __________________________________________________________________________
List all surgical procedures you may have had and the date(s): ______________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Form 005 | 9/2014
Across The Tracks Healthcare
205 East 19th Street North
Big Stone Gap, VA 24219
Phone: (276) 523-4890 Fax: (276) 523-4541
www.acrossthetrackshealthcare.weebly.com
Donald E. Dingus II, MD Cassandra R. Dingus, MSN, FNP
CIRCLE ALL THAT APPLY:
GENERAL SYMPTOMS
Fatigue/excessive tiredness
Fever
Night sweats
Victim-domestic violence
Weight gain (unintentional)
Weight loss (unintentional)
EYES
Seasonal allergies
Blurred vision
Wear glasses or contacts
EARS/NOSE/THROAT
Ears pain
Hearing problems
Nasal congestion
Non-healing nasal ulcer
Runny nose (frequent)
Sore throat
Tooth pain
HEART AND CIRCULATION
Chest pain
Dizziness
Palpitations/irregular heartbeat
Swelling of feet/ankles
Episodes of fast heart rate
LUNGS AND BREATHING
Cough (chronic)
Shortness of breath
Coughing up blood
Wheezing
STOMACH/INTESTINES/
DIGESTION
Abdominal pain
Acid reflux
Loss of appetite
Abdominal bloating
Difficulty swallowing
Constipation
Diarrhea
Heartburn
Hemorrhoids
Dark, tarry stools
Nausea
Vomiting
GENITAL AND URINARY SYSTEM
painful urination
genital lesions
blood in urine
high risk (for HIV) sexual behavior
frequent urine infections
Irregular menstrual cycle
Very heavy bleeding with periods
Painful Periods
Vaginal bleeding after intercourse
Rape (history of)
Victim of sexual abuse
Vaginal discharge
Vaginal itching
MUSCLES AND BONES
Joint aches
Back pain
Joint stiffness
Muscle aches
SKIN/BREASTS
Acne
Mole(s) that concern you
Dry skin
Fungal nail infection
Yellowing of skin or eyes
Excessive itching
Rashes
Wart(s)
Breast mass
Breast skin changes
Breast tenderness
Nipple discharge
Do you perform self breast exams
HORMONES
hot flashes
darkening of skin color
infertility
excessive thirst
excessive hunger
Hair loss
Intolerant to hot/cold temps
Excessive body hair growth
Year-round allergies
Frequent colds
HIV risk factors
PSYCHIATRIC
Anxiety
Depression
Feeling stressed
Mood Swings
Personality change
PMS (premenstrual syndrome)
Difficulty concentrating
Problems falling asleep
Suicidal thoughts
NERVOUS SYSTEM
Dizziness
Fainting
Headaches
BLOOD AND LYMPH SYSTEM
Easy bruising
Excessive bleeding
History of blood transfusion
Swollen lymph nodes
Form 005 | 9/2014
Across The Tracks Healthcare
205 East 19th Street North
Big Stone Gap, VA 24219
Phone: (276) 523-4890 Fax: (276) 523-4541
www.acrossthetrackshealthcare.weebly.com
Donald E. Dingus II, MD Cassandra R. Dingus, MSN, FNP
REQUEST / CONSENT TO DISCLOSE HEALTH INFORMATION
Patient Name: __________________________________________DOB____________________________
I hereby request that health information be discussed with and disclosed to the family members, relatives, or friends
of listed below. The individuals identifies below are involved in my care and/or payment for my care, and I agree that
the provider listed above may share such information as the provider may deem relevant to such individual’s
involvement, including appointment time, required care and diagnoses. I understand that I have the right to revoke
this request/consent by delivering written notice to the provider:
PLEASE LIST INDIVIDUALS:
Name: _________________________________________Phone#:_________________________________
Relationship to patient: __________________________________________________________________
Name: _________________________________________Phone#:_________________________________
Relationship to patient: __________________________________________________________________
Name: _________________________________________Phone#:_________________________________
Relationship to patient: __________________________________________________________________
Signature of Patient or Authorized Representative
Date
______________________________________________
__________________________
Authority (if not signed by patient) ________________________________________________________
Form 005 | 9/2014
Across The Tracks Healthcare
205 East 19th Street North
Big Stone Gap, VA 24219
Phone: (276) 523-4890 Fax: (276) 523-4541
www.acrossthetrackshealthcare.weebly.com
Donald E. Dingus II, MD Cassandra R. Dingus, MSN, FNP
Dr. Donald E. Dingus II, M.D.
Cassandra R. Dingus, MSN, FNP
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL HEALTH CARE INFORMATION
Patient Name: __________________________________________Date of Birth: ___________________
Street Address: ________________________________________________________________________
City: _____________________________________ State:_______________ Zip: _________________
This authorizes Across The Tracks Healthcare Family Medicine and Urgent Care Clinic to request and receive
from the Virginia Department of Health Professions any and all records held by the Department relating to
Schedule II-V controlled substances dispensed to the patient named above.
I understand that this authorization permits the Department of Health Professions to disclose confidential health
care records to the prescriber named above. A copy of this authorization shall be included with my original records.
There is a potential for any information disclosed pursuant to this authorization to be subject to re-disclosure as
permitted or required by law.
I understand that, if not previously revoked, this consent will expire one year after the date of my signature unless
otherwise specified.
Patient Signature: _____________________________________________ Date: __________________
Guardian Signature: ___________________________________________ Date: __________________
NOTE: This authorization form is in addition to and separate from any other disclosure forms that you may have
signed.
Form 005 | 9/2014
Across The Tracks Healthcare
205 East 19th Street North
Big Stone Gap, VA 24219
Phone: (276) 523-4890 Fax: (276) 523-4541
www.acrossthetrackshealthcare.weebly.com
Donald E. Dingus II, MD Cassandra R. Dingus, MSN, FNP
CONSENT TO PHOTOGRAPH
By signing below, I understand that photograph, digital, or other images may be
made to document my care in the event that I cannot produce photo
identification at time of check-in. I understand that Across the Tracks
Healthcare will retain ownership rights to these photographs or digital images.
I understand that these images will be stored in a secure manner that will
protect my privacy.
Signature: __________________________________________________
Relationship: _______________________________________________
Date/Time: __________________________________________________
Witness Signature:___________________________________________
Form 005 | 9/2014
Across The Tracks Healthcare
205 East 19th Street North
Big Stone Gap, VA 24219
Phone: (276) 523-4890 Fax: (276) 523-4541
www.acrossthetrackshealthcare.weebly.com
Donald E. Dingus II, MD Cassandra R. Dingus, MSN, FNP
CONSENT FOR TREATMENT
1.
GENERAL CONSENT FOR TREATMENT AND TESTS: I consent to treatment by the physician and/or nurse
practitioner and staff at Across The Tracks Healthcare Family Medicine and Urgent Care Clinic for my illness
and /or health evaluation, including but not limited to, x-rays, tests, laboratory procedures, medications, and
minor procedures. I acknowledge and agree that NO guarantees have been made to me as to the results or
outcome of my medical care. I understand that State Law requires physicians to report certain
communicable diseases.
2. RELEASE FROM LIABILITY FOR LEAVING AGAINST MEDICAL ADVICE: I agree that if I leave the physician’s
office against the advice of Donald Dingus II, MD or Cassandra R. Dingus, MSN, FNP, or its personnel, then
the staff of Across The Tracks Healthcare, is released from responsibility or liability or damages that may
result from my leaving against medical advice.
3. PHONE AUTHORIZATIONS : I authorize Across The Tracks Healthcare to contact me by phone. I understand
if I cannot be reached, a message may be left at my designated phone number _______________________.
4. PHONE MESSAGES: I authorize Across The Tracks Healthcare, to leave a message on my phone in regards to
appointment times.
I HAVE READ AND UNDERSTAN D THIS DOCUMENT AND I AGREE TO ITS TERMS.
Patient or authorized signature: _____________________________________ Date: _____________________
Witness: _________________________________________ Date: _____________________________________
Form 005 | 9/2014
Across The Tracks Healthcare
205 East 19th Street North
Big Stone Gap, VA 24219
Phone: (276) 523-4890 Fax: (276) 523-4541
www.acrossthetrackshealthcare.weebly.com
Donald E. Dingus II, MD Cassandra R. Dingus, MSN, FNP
PATIENT AUTHORIZATION
Patient Name:_________________________________________DOB_____________________________
SSN:_______________________________ Date(s) of Treatment_________________________________
I, hereby authorize staff members, employees, or other agents of: _______________________________________________
Name of Organization
To use or disclose the following protected health information:
_____Copy of the Complete Record(s)
_____Lab Report(s)
_____Hx/Physical Examination
_____Radiology Report(s)
_____Progress Notes
_____Pathology Report(s)
_____Discharge Summary
_____Emergency Dept. Records
_____Operative Report
_____Other as specified below
(If this form authorizes the use or disclosure of psychotherapy notes, it may not be used to authorize the use or disclosure of
any other Protected Health Information. A separate authorization is needed for any other use or disclosure.) If this form
authorizes the use of disclosure of Alcohol/Drug Abuse Information, it may not be used to authorize the use or disclosure of any other
Protected Health Information. A separate authorization is needed for any other use or disclosure. Furthermore, receiver of this information
must abide by Federal Confidentiality Rules, 42 CFR part 2, which states The Federal Rules prohibits you from making further disclosures of
this information unless further disclosure is expressly permitted by 42 CFR, part 2. A general authorization for the release of medical or
other information IS NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or
prosecute any alcohol or drug abuse patient.
This information is to be released to : Across The Tracks Healthcare, Family Medicine and Urgent Care Clinic about me for the following
purposes:
_____At the direction or request of the undersigned individual
_____ For marketing. This organization will/will not (cross out one) receive compensation, whether monetary or otherwise, as a result of the
use or disclosure of you my health information for marketing purposes
_____ For research (describe)______________________________________________________________________
_____ Other (describe)___________________________________________________________________________
(If you need more space to explain, please write it on the back of the form)
This authorization expires on the following data ________/________/_________ or when the following event occurs:
_____ No expiration (permitted only for authorizations used to create or maintain research databases or repositories).
_________________________________________________
Patient’s Signature
________________________________________________
Responsible Party (if minor or incapacitated)
_____________________________________________
ATTH Employee Witness
_____________________________________________
Date
Time
Form 005 | 9/2014
Across The Tracks Healthcare
205 East 19th Street North
Big Stone Gap, VA 24219
Phone: (276) 523-4890 Fax: (276) 523-4541
www.acrossthetrackshealthcare.weebly.com
Donald E. Dingus II, MD Cassandra R. Dingus, MSN, FNP
HIPAA NOTICE
As a patient, you have certain rights as to what healthcare information is
disclosed about you and/or your medical records. A copy of this information,
privacy policies and procedures, and patient rights is available to all patients
upon request. There are copies posted in the waiting room, triage, and
treatment rooms. You may also obtain a copy on our website
www.acrossthetrackshealthcare.weebly.com. By signing this form, you
acknowledge that you are aware of the privacy policies and a copy has been
available to you. If you have any questions, please see the HIPAA Compliance
Officer of this facility. He / She may be reached during normal business hours.
Patient or Legal Guardian Signature:
__________________________________
ATTH Employee Witness: _____________________________________________________
Date: _____________________________
Form 005 | 9/2014
Across The Tracks Healthcare
205 East 19th Street North
Big Stone Gap, VA 24219
Phone: (276) 523-4890 Fax: (276) 523-4541
www.acrossthetrackshealthcare.weebly.com
Donald E. Dingus II, MD Cassandra R. Dingus, MSN, FNP
PATIENTS PLEASE KEEP THIS FORM
HIPAA notice describes how medical information about you may be used and disclosed and how you can get access to this
information. Please review it carefully.
This notice describes how medical information about you may be used and disclosed and how you can get access to this
information. Please review it carefully
This notice of privacy practices describes how we may use and disclose your protected health information (PHI) to carry out
treatment, payment or health care operations (IPA) and for other purposes that are permitted and required by law. It also
describes your rights to access and control your protected health information. “Protected health information” is information
mental health or condition and related health care services.
Uses and Disclosure of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office
that are involved in your care and treatment for the of providing health care services to you, to pay your health care bills, to
support the operation of the physician’s practice, and any other use required by law.
TREATMENT: We will use and disclose your protected health information to provide, coordinate, or manage your health care
and any related services. This includes the coordination or management of your health care with a third party. For example,
your protected health information may be provided to a physician to whom you have been referred to ensure that the physician
has the necessary information to diagnose or treat you.
PAYMENT: Your protected health information will be used, as needed, to obtain payment for your health care services. For
example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the
health plan to obtain approval for the hospital admission.
HEALTHCARE OPERATIONS: We may use or disclose, as needed, your protected health information in order to support the
business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities,
employee review activities, and conducting or arranging for business activities. For, we may use a sign-in sheet at the
registration desk where you will be asked to sign your name and indicate your physician. We will also call your name in the
waiting room when the physician is ready to see you. We may use your protected health information to contact you to remind
you of an existing appointment.
We may use your protected health information in the following situations without your authorization. These situations
include: as requested by law, public health issues required by law, communicable diseases, health oversight, abuse or neglect,
food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, and organ
donation, research, criminal activity, military activity and nation security.
Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object
unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physicians practice has
taken an action in reliance on the use or disclosure indicated in the authorization.
Form 005 | 9/2014