Contact Us
Audiology301-695-EARS (3277)

Medical Group

Brain & Spine
301-846-0100

Hello, and welcome to Frederick Health Medical Group!

Breast Center
301-418-6611

We appreciate the value of your time. Here are some tips tohelp us provide comprehensive care in an efficient manner:

Chest Surgery
301-694-5861• Please bring your insurance card and photo ID with you.

Comprehensive Care Center
301-360-2574• Payment is expected at time of service. We accept
cash, checks, and all major credit cards.
• For patients visiting one of our specialists: if you are amember of an HMO, please contact your primary care
physician to obtain a referral. Most offices require 48
hours’ notice to issue a referral.
• For all new patients to our practices, please haveappropriate records forwarded to us before yourappointment. Your Doctor’s office will either mail or fax
them to our office, but you must request them. This
includes any recent office notes, labs, or imaging.
• Please complete the attached paperwork and have it
ready when you arrive for your visit.
• You may be asked to reschedule if you arrive after
your check in time.
We are working hard to ensure your time with us is as
pleasant as possible. We are committed to your care andvalue any feedback you may have for us. Thank you and welook forward to seeing you!
Respectfully,Your providers and staff at Frederick Health Medical Group

Ear, Nose & Throat(Otolaryngology)301-695-3100
Endocrine & Thyroid
240-215-1454
Gastroenterology
240-566-4820
Infectious Disease240-566-3270
Medical Weight Loss
240-215-1474
Oncology & Hematology
301-662-8477
Orthopedics & Sports Medicine
301-663-9573
Precision Medicine & Genetics
301-663-9985
Primary Care
240-215-6310
Pulmonary Medicine
240-566-3201
Sleep Medicine
240-566-REST (7378)
Surgery240-575-2526
Urology301-663-4774
Wound Care & Hyperbaric Medicine
240-566-3840

Patient Compact
PRINCIPLES OF PARTNERSHIPAs your healthcare partner, we pledge to:

As a patient, I pledge to:• Respect you as leader of the team.

• Be a responsible and active member of my healthcare
team, and participate in decisions about my care.

• Allow you to select a personal provider and careteam who will know you.
• Treat you with respect, honesty and compassion.
• Include your family, other partners or an advocate inyour care when you request.
• Hold ourselves to the highest quality
and safety standards.
• Be responsive and timely with our care andinformation to you.
• Listen to you and answer your questions.
• Provide information to you in a way
you can understand.
• Help you to set goals for your healthcare
and treatment plans.
• Provide you with information to help you
make informed decisions about your careand treatment options.
• Communicate openly about benefits and risks
associated with any treatments.
• Respect your right to your own medical information.
• Respect your privacy and the privacy of
your medical information.
• Work with you, and other partners who treat you, inthe coordination of your care.
• Provide educational resources, information aboutclasses, support groups, or other services that canhelp you learn more about your condition.

• Treat the whole team with respect,consideration and always tell the truth.
• Give you the information that you need to treat me.
• Tell you what medications/supplements I am taking.
• Inform you of all other provider visits, tests
ordered, and medications prescribed by themand have them send us reports of your visit.
• Tell you if something about my health changes andany changes in my family, medical and social history.
• Learn about my health condition and let you
know if there is something I do not understand.
• Understand my care plan to the best of my ability andfollow my care plan that I have agreed upon or let you
know if there are issues so the plan can be changed.
• Take all medications as prescribed andcommunicate to my team if there areissues such as cost or side effects.
• Communicate any questions using
the patient portal or by phone.
• Tell you if I have trouble reading or hearing.
• Let you know if I have family, friends or an
advocate to help me with my healthcare.
• Work with Frederick Health Medical Group andmy insurance company to understand what myinsurance plan covers. I will pay my share of any fees.
• I will come to all scheduled appointments ontime. I will give at least 24 hours’ notice if I
must cancel an appointment, unless there is an
emergency that prevents me from giving notice.

REV: 03/2024

Choosing the Right Level of Care
IN A MEDICAL EMERGENCY

Everyone knows that a primary care doctor is the best place to go when you are sick or in pain. By
seeing your primary care physician on a regular basis, they will have your complete health history and anunderstanding of any underlying conditions you may have.
Sometimes you become sick or injured when the doctor’s office is closed, and sometimes you need moreurgent medical attention than your doctor can provide. This handout helps to explain where to seek
the best care inyour time of need.

If you believe a life is in jeopardy, always call 911!

Primary Care

■ Treatment of illness, including:Call to make an
appointment with yourprimary care provider if
you have symptoms of aregular illness or need aregular check-up.

Urgent Careis an option
if you have aminor illness
or injury, yourprimary careprovider is notavailable, andyour problem
cannot wait.

■ Chronic conditions, including:Colds and coughs

Diabetes

Sore throat

Heart Disease

Flu and flu-like symptoms

COPD

Ear infections■ General medical advice

Urinary tract infections■ Annual Well Exams

Minor aches and pains■ Immunizations

Allergies■ Respiratory problems■ Treatment of illness, including:Colds, coughs, and upper
respiratory infections;
Sore throat;
Flu and flu-like symptoms;
Ear infections/Earache;
Suspected urinary tract infection;
Sexually Transmitted Illness;
Fever—if seizing, go to Emergency Dept.
■ Upset stomach■ Nausea or vomiting■ Adult IV hydration■ Skin rashes and infections■ Abscesses■ Sprains or suspected minor broken bones■ Musculoskeletal injuries■ Back pain or joint pain
■ Toothache (if dentist is not available)■ Allergies■ Animal or insect bite
■ Eye irritation and redness■ Minor cut/abrasion and sutures/stitching■ Minor burn
■ Frequent, bloody, or painful urination■ Motor Vehicle Collision exams■ Workman’s Comp exams■ Sports/DOT physicals■ Travel vaccines■ Laboratory and blood work
■ X-Rays

Choosing the Right Level of Care
IN A MEDICAL EMERGENCY
Emergency
Department(ED)
is open 24
hours a day, 7days a week.
Seek care atthe Emergency
Department
without delay
if you have aserious or alife-threatening
illness or injury.

■ Chest pain or other heart attack symptoms:

Pressure, fullness, squeezing/painin the center of your chest
Tightness/burning/achingunder the breastbone
Chest pain with lightheadedness■ Signs of a stroke, such as:

Sudden weakness or numbness of theface/arm/leg on one side of the body
Sudden dimness or loss of vision
Loss of speech or trouble talking
Sudden severe headaches with no cause■ Head injury or eye injury■ Sudden and severe headache orloss of vision■ Heavy bleeding that won’t stop

If you believe a life is injeopardy, always call 911!

■ Dislocated joints■ Severe abdominal pain
■ Deep cuts or severe burns■ High fever■ Severe asthma attack■ Loss of consciousness■ Severe or worsening reaction to an

insect bite, sting, or medications■ Constant, severe/persistent vomiting■ Coughing up or vomiting blood■ Poisoning—call Poison Control at

1-800-222-1222 and ask for
immediate home treatment advice■ Domestic violence or rape
■ Feelings of suicideA Better Approach to Your Healthcare
PATIENT-CENTERED MEDICAL HOME

No matter your healthneeds, your primarycare provider is here
to help you maintaina healthy lifestyle.
Evidence shows thataccess to primary carehelps people live longer,
healthier lives1—andpatients with access toregular primary careproviders have lower
overall healthcare costs. 2

Accessible

Personalized

Shorter wait times, “after-hours” care, 24/7
telehealth access, and stronger communication

Addresses
your personal
health concerns
and needs

Committed to quality & safety
Evidence-based medicine and clinical support

Comprehensive
A team of care providers—fromphysicians to nurses to nutritionists tosocial workers—for prevention, wellness,acute care, and chronic care

CoordinatedOpen communication across all parts ofthe broader healthcare system, especiallyduring transitions between sites of care

Patient-centeredSupportive &encouraging
Advice via phone,email, text, etc.
from your healthteam to help you
meet your goals
and support you
with health issues
and concerns

Efficient
Saves you time

Provides the education and resources youneed to make smart decisions and become
an active participant in your own care
1.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145/#b62

2.

Source: https://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/twentiethreport.pdf

What is apatientcentered
medical home
(PCMH)?
It’s an innovative
approach toprimary care thatmeets patientswhere they are—in
the right place, atthe right time, andwith the right care.

It’s not aplace—it’s apartnershipwith yourprimary careprovider.

When you think PCMH, think
Frederick Health Medical Group!

Why Frederick Health
Medical Group?
Frederick Health Medical Groupis recognized by the National
Committee of Quality Assurance asa PCMH. We partner with you andyour healthcare team to provide thehighest level of primary care possible.

With Frederick Health Primary Care, your healthcare team...
• Is just a phone call or portal message away
• Is your access point to Frederick Health and its wide array ofservices and specialists

9 locations throughout
Frederick County• Collaborates with specialists to address all aspectsof your healthcare

Lower hospital
readmission rates
after a health event• May include a number of specialists, like in-house carecoordinators, patientnavigators, lab assistants, licensed clinicalsocial workers, and more
• Offers telehealth, including email messaging and nurse access
via the phone• Offers the same level of service and care, no matter yourinsurance provider or payer

Call 240-215-6310 to find a primary care provider
today, or visit frederickhealth.org/PrimaryCare

National Committee
for Quality Assurance
certifiedOpen 7 days a week
Same-dayappointments

Patient Registration

Medical Group

Patient Information
PREFERRED FIRST NAME

ZIP CODEHOME PHONE

WORK PHONE

CELL PHONE

PREFERRED CONTACT METHOD (Check all that apply):WOULD YOU LIKE TO JOIN THE PATIENT PORTAL?

□ Cell Phone □Home Phone □Work Phone □Home Address (Letter) □Portal□Yes □No

PRIMARY CARE PROVIDER:

REFERRING PROVIDER (if applicable):□Full Time □Part Time □Self-Employed □Not Employed□Retired □Homemaker □Active Military □Unknown

OCCUPATION:EMPLOYER PHONE:
EMPLOYER ADDRESS:INTERPRETER NEEDED?

PRIMARY LANGUAGE:□Yes □No
MARITAL STATUS□Yes □No

VETERAN STATUS:
PRONOUNBIRTH SEXLEGAL SEX

□ Decline to Answer□ Female□ Married□ Female□ Annulled□ MaleMale□□ Choose Not to Disclose □ Married, Common Law □ He/Him/His
Undifferentiated□
She/Her/Hers
Non-Binary□
Single□□Divorced□□
They/Them/Their
Other□
Unknown□
Separated
Legally□□
Unknown/Undifferentiated
Ze/Hir□□Life
Partner
Widowed□□ Not Listed (please specify):
ETHNICITY

RACE□ Decline to Answer□ Decline to Answer □ Black or African American □ White/Caucasian□ American Indian/ □ Native Hawaiian/□ Unknown/Unable to Answer □ Cuban
Pacific Islander□ Hispanic or Latino
Alaskan Native□ Other:Asian□□ Mexican or Chicano
SEXUAL ORIENTATION
Decline to Answer□□ Straight/Heterosexual□ Bisexual/Pansexual□ Lesbian/Gay/Homosexual□ Don't Know
□ Not Listed (please specify):
REV 4/2024□ Not Hispanic or Latino□ Other Hispanic Origin□ Puerto Rican□ Unknown/Unable to Answer

GENDER IDENTITY□ Decline to Answer□ Female□ Male□ Non-binary/Genderfluid□ Transgender Female□ Transgender Male□ Not Listed (please specify):
CONTINUED ON REVERSE

Insurance Information
PRIMARY INSURANCE CARRIER

SECONDARY INSURANCE CARRIERGROUP#GROUP#DATE OF BIRTH

ADDRESSRELATIONSHIP TO PATIENT:□ Same as Patient□ Spouse

PHONE

ADDRESSPHONE

RELATIONSHIP TO PATIENT:□ Same as Patient□ Spouse□ Parent□ Other□ Parent□ Other□ Work Related □ Auto Related □ Neither
Responsible Party/Guarantor
RESPONSIBLE PARTY NAME (First, Middle, Last)
ADDRESSDATE OF BIRTH(Policy Holder)

DATE OF BIRTHHOME PHONEEMPLOYER
WORK PHONE

RELATIONSHIPTO PATIENT:SEX:DATE OF INJURY□ Parent □ Guardian □ Self
□ Spouse □ Other□ Female □ Male □ UndifferentiatedEmergency Contact
EMERGENCY CONTACT NAME

RELATIONSHIP TO PATIENTEMERGENCY CONTACT PHONE

All Payment Is Due at Time of Service
I authorize payment of insurance benefits directly to Frederick Health Medical Group. Payment is due uponreceipt of service. I will be responsible for fees and charges according to Frederick Health Medical Group andmy health plan. If I do not provide a valid insurance card at each visit, I will be held responsible for services. I
understand that I may be contacted by Frederick Health Medical Group and/or its affiliates on my cellular orhome phone, which may include the use of Pre-recorded/artificial voice messages and/or an automatic dialing
device (“auto dialer”), by text message, or email in connection with any communication made to me or related
to my accounts even if I am charged for the call under my phone plan.

DATE

RELATIONSHIP TO PATIENT

REV 4/2024

Health Insurance Portability andAccountability Act (HIPAA)

Medical Group

This form applies to all specialties within Frederick Health Medical Group.

Acknowledgement of Receipt of Privacy NoticeI, patient (or representative for patient) of Frederick Health Medical Group, have been offered a copy of the Noticeof Privacy Practice, which describes my privacy rights in accordance to federal and state requirements.
DATE

Communication Consent
I understand that I may be contacted by Frederick Health/Frederick Health Medical Group and or its affiliates on mycellular or home phone, which may include the use of pre-recorded/artificial voice messages, and /or an automateddialing device (auto dialer) or by text message or email in connection with any communication made to me or related
to my accounts even if I am charged for the call under my phone plan. I understand that providing my phone number is
not required to obtain services. You may also contact me by e-mail using any e-mail address I have provided to you.

□ Yes, you may call or text my cell phone at:This communication is to conﬁrm office appointments or leave a message regarding my care.

□ No, please do not contact me by the following means:

I authorize my provider and the appropriate staff to share clinical/medical/billing information about my care/accountto the following individuals as indicated below as my Next of Kin and Person to Notify.

NAME of Next of Kin

RELATIONSHIPPHONELANGUAGE

NAME of Person to Notify

RELATIONSHIPPHONELANGUAGE□ Same as Next of Kin

It is the patient’s responsibility to notify Frederick Health Medical Group of any changes to this form.

PATIENT’S DATE OF BIRTH

HOME/CELL PHONE NUMBER (PLEASE CIRCLE ONE)DATEWITNESS		

DATE

FrederickHealth.org

Patient Health History

Medical Group

PATIENT NAME (First, Middle, Last)

DATE OF BIRTH

OCCUPATIONPRIMARY CARE PROVIDER (First and Last Name)

PHARMACY PREFERENCE (Include location)
DATE OF ONSET OF ILLNESS/INJURYREASON FOR VISIT

Did the fall(s) result in an injury? □ Yes □ No
□ Yes □ No How many times?
Do you use a walking aid or has one been recommended? □ Yes □ No □ N/A Details:

Have you fallen in the past year?

Past Medical History Check all conditions you have now or have had in the past.
CANCER□ TYPE:HEENT (Head, Eyes, Ears, Nose & Throat)

YEAR:

CANCER□ TYPE:YEAR:

CANCER□ TYPE:YEAR:

CARDIOVASCULAR (Heart & Blood Vessels)□ Angina (chest pain)□ Arrhythmia/irregular heartbeat□ Blood clot/DVT (deep vein thrombosis)
DATE:□ Heart attack/MI DATE:□ Heart disease/Coronary artery disease□ High cholesterol/Hyperlipidemia□ MVP (mitral valve prolapse)□ Varicose veins/Peripheral vascular disease□ Hypertension/High blood pressure□ Pacemaker YEAR:□ Stent DATE:□ AICD (Automatic Implantable Cardioverter Defibrillator)
BONES, JOINTS & MUSCLES□ Arthritis□ Fibromyalgia□ Gout□ Osteoporosis

MENTAL HEALTH□ Anxiety DATE:□ Bipolar Disorder DATE:□ Depression DATE:□ Drug/Alcohol abuse DATE:□ OTHER:DATE:

Other medical conditions not listed above:□ Blind DATE:□ Deaf DATE:□ Hearing loss DATE:□ Glaucoma DATE:PULMONARY/RESPIRATORY□ Asthma□ Emphysema□ COPD (chronic obstructive pulmonary disease)□ PE (pulmonary embolism/blood clot in lung)
DATE:□ Pneumonia□ Sleep Apnea□ Currently uses a C-PAP machine□ TB (tuberculosis) DATE:GENITOURINARY (Kidneys & Urinary Tract)□ Renal failure□ Renal insufficiency□ UTI (urinary tract infection)

NEUROLOGIC DISORDER (Brain &Nervous System)□ Alzheimer’s disease□ Dementia□ MS (Multiple Sclerosis)□ Parkinson’s disease□ Seizure disorder□ Stroke/CVA/TIA DATE:□ Myasthenia gravis□ Muscular dystrophy□ Migraines□ Scoliosis□ Rheumatoid Arthritis

HEMATOLOGIC (Blood & Lymph Node)□ Anemia□ Hemophilia□ Sickle cell disease□ Clotting disorders□ Lupus

GASTROINTESTINAL (Stomach & Digestive)□ Colon polyps□ Hepatitis A□ Hepatitis B□ Hepatitis C□ Hepatitis – Type unknown□ Hernia□ Irritable bowel□ Stomach ulcer□ Liver disease/Cirrhosis□ Acid Reflux□ Crohn’s Disease□ Ulcerative Colitis

ENDOCRINE (Hormones & Metabolic)□ Diabetes – Type I□ Diabetes – Type II□ Diabetes – Type unknown□ Thyroid dysfunction□ Hypothyroidism (low)□ Hyperthyroidism (high)□ Hemoglobin A1C□ Thyroid Cancer

IMMUNE/AUTOIMMUNE &INFECTIOUS PROBLEMS□ AIDS DATE:□ HIV positive DATE:□ MRSA (Methicillin Resistant Staph Aureus)
DATE:□ Lyme’s Disease DATE:REV 12/2022

Past Surgical History Check all that apply and indicate which side R/L as appropriate.

□ Joint surgery YEAR:□ Aneurysm YEAR:□ Angioplasty YEAR:□ Angio w/stent YEAR:□ Appendectomy YEAR:□ Arthroscopy YEAR:LOCATION:□ Back surgery YEAR:□ Cardiac/Heart surgery YEAR:□ Cataract extraction YEAR:□ Colectomy YEAR:□ Colonoscopy YEAR:□ C- Section YEAR:

R/L

R/L

R/L

□ Ear Tubes YEAR:□ Gallbladder YEAR:□ Gastric bypass YEAR:□ Hernia repair YEAR:□ Hip replacement YEAR:□ Hysterectomy YEAR:□ Knee replacement YEAR:□ Breast Surgery YEAR:□ Prostate YEAR:□ Thyroidectomy YEAR:□ Tonsillectomy YEAR:□ Tubal Ligation YEAR:□ Vasectomy YEAR:OTHER SURGERIES NOT LISTED:□ OTHER□ OTHER□ OTHER□ OTHER□ OTHER

R/L

Ovaries: R/L
R/L

YEAR:
YEAR:
YEAR:
YEAR:
YEAR:

□ Problems with Past Anesthesia (if yes, please list below):

R/L

CURRENTLY BEING TREATED WITH:□ Dialysis□ Chemotherapy□ Radiation□ Oxygen (Day/Night)

litersFamily History Has any member of your family (blood relatives) had one or more of the following diseases? If so, please mark thecheckbox next to the condition and indicate which family member beside the condition name.

□ Cancer/Type□ Cancer/Type□ Cancer/Type□ Cancer/Type□ Heart disease□ Stroke□ Diabetes□ Alcoholism□ High blood pressure□ Depression□ Sickle Cell
□ Tuberculosis□ Glaucoma□ Asthma□ High Cholesterol□ Kidney disorder□ Dementia□ Gout□ Suicide□ Epilepsy□ Thyroid disorder□ Bleeding disorderSocial History
ALCOHOL USE□ None □ Rarely (social) □ Often # of Drinks per week:
What type of alcohol do you drink? □ Beer □ Wine □ Hard liquor□ QuitDo you drink alcohol?

CAFFEINE USE□ Daily

AMOUNT & TYPE

□ Sometimes□ Never

AMOUNT & TYPETOBACCO USE: PRESENTDo you currently smoke cigarettes regularly (at least one a day)?

□ No □ Yes

Currently on average, how many cigarettes do you smoke per day? (one pack = 20)
TOBACCO USE: PAST# OF CIGARETTES:In the past, have you ever smoked cigarettes regularly (at least 100 cigarettes)?

□ No □ Yes

How many years have you smoked cigarettes regularly (at least once a day)?

YEARSIn the past on average, how many cigarettes did you smoke per day? (one pack = 20)
If you have quit smoking, what year did you quit?
Do you currently smoke cigars/pipe/smokeless tobacco?
VAPING

Do you vape?

□ Not currently □ Currently# OF CIGARETTES:□ No □ Yes

If you currently vape, how long have you been vaping?

What type of device(s) do you use?
How many times per day do you vape?
Do you vape for social reasons or in an effort to quit smoking?
REV 12/2022

If so, when?

Current Strength:

Previous Strength:

Social History, continued
DRUG USE□ No □ Yes If you answered “Yes,” what type(s)?
□ No □ Yes If you answered “Yes,” what type(s)?

Present
Past

Age quit:

Date quit:

Medications Please list any medication(s) you are currently taking, include prescribed medications, vitamins, supplements, andover-the-counter medications.
MEDICATIONDOSAGE/DIRECTIONSPROBLEM BEING TREATEDPRESCRIBING DOCTOR□ Medication List Copied—see attached Medication List
Are you being treated by pain management?

□ Yes □ No

If so, where?

Allergies Please indicate your known allergies using the checkboxes below:□ Aspirin□ Penicillin□ Codeine□ Sulfa□ Latex□ Betadine□ Tape□ IVP dye
□ Iodine/shellfish□ Eggs, birds/feathers□ Contact dermatitis□ Other:□ I have no known allergies

Please describe your reaction(s) to allergens, if any:

Current Treating Physicians
CARDIOLOGISTPULMONOLOGISTNEUROLOGISTENDOCRINOLOGISTHEMATOLOGIST/ ONCOLOGISTOTHER

PATIENT/GUARDIAN SIGNATURE

REV 12/2022

DATE OF BIRTHDATE