COVID 19 Warning: Ocotillo Internal Medicine is dedicated to the health of our patients. Due to the increase in COVID 19 cases and deaths in Arizona we will continue with the following precautions: 1. Majority of visits will be done virtual by Telemedicine, 2. Any patient who comes into the office must have an appointment, be prescreened by a staff member and wear a mask while in the office.3. All of our staff members and providers will be required to wear a mask and we will continue our intensive sanitation measures. 4. Instead of coming into the office, you may do your visit virtually via telemedicine which insurance covers just as any other visit. If you would like to convert you appointment to telemedicine and not have to come into the office please contact the office to make the change. We understand that some of these measures are inconvenient but it is for the safety of all.

T: 480.895.5870
F: 480.895.0573
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Full Patient Packet

OIMA Patient Packet
**PLEASE CHECK IN 15 MINUTES PRIOR TO YOUR APPOINTMENT WITH FORMS COMPLETED**
Patient Information
Name*
First Last
Date of Visit*
MM slash DD slash YYYY
Hidden
Primary Provider at Ocotillo Internal Medicine
- Drew Hall
- Lily Delatte
- Nicholas Vlahos, MD
Physician(s) You See
Medications
Please list all prescribed or over the counter medications.
List
Name of Medication Dose ( mg, ml ) # of tablets or capsules each dose # of times per day
Medication Allergies
Have you had an allergic or adverse reaction to any medication?
- Yes
- No
List Medication Allergies
Medication Type of Reaction
Medical History
Check all that apply.
Your Medical History:
- Hearing loss
- Cataracts
- Asthma
- Hayfever
- COPD
- Valley Fever
- Lung Nodule
- High Blood Pressure (Hypertension)
- Heart Attack (myocardial infarction)
- Congestive Heart Failure
- Atrial Fibrilation
- Elevated Cholesterol (hypercholesterolemia)
- Acid Reflux (GERD)
- Crohn's Disease
- Ulcerative Colitis
- IBS ( irritable bowel syndrome )
- Hep. A
- Hep. B
- Hep. C
- Ulcer of stomach or esophagus
- Chronic Constipation
- Osteoarthritis
- Rheumatoid Arthritis
- Fibromyalgia
- Lupus
- Osteoporosis
- Osteopenia
- Other
Please check all that are applicable.
Other:
Your Medical History 2:
- Diabetes
- Melitus
- Hypothyroidism (low thyroid)
- Hyperthyroidism (high thyroid)
- Menopause (women only)
- Polycystic ovarian disorder (women only)
- Kidney disease
- Kidney stones (nephrolithiasis)
- Enlarged Prostate (men only)
- Frequent urinary tract infections
- Stroke or TIA
- Migraine headaches
- Seizures
- Dementia
- Parkinson's Disease
- Skin Cancer
- Eczema
- Anemia
- Leukemia
- Lymphoma
- Blood clot
- Depression
- Anxiety
- Eating Disorder
- Attention Deficit Disorder
- Bipolar Disease
- Cancer? Please list type below
Please check all that are applicable.
Please list types of cancer:
Surgical History
Check all that apply.
Surgical History
- Appendectomy
- Removal of gallbladder (cholecystectomy)
- Colon surgery
- Breast surgery
- Prostrate surgery
- Tubal ligation
- Vasectomy
- Hysterectomy
- Removal of ovaries (oophorectomy)
- Join replacement - specify
- Cardiac Bypass
- Pacemaker
- Valve replacement
- Cardiac catch with stent
- Other
Please check all that are applicable.
Joint Replacement details:

If Joint replacement or other, please specify below.
Other:
Family History
Is Your Mother Living?
- Yes
- No
Mother's Deceased/Age
Mother Medical Problems
- Diabetes
- Heart Disease
- Breast cancer
- Colon cancer
Is Your Father Living?
- Yes
- No
Father's Deceased/Age
Father Medical Problems
- Diabetes
- Heart Disease
- Breast cancer
- Colon cancer
Do You Have Sisters?
- Yes
- No
Sister's Deceased/Age
Sisters Medical Problems
- Diabetes
- Heart Disease
- Breast cancer
- Colon cancer
Do You Have Brothers?
- Yes
- No
Brother's Deceased/Age
Brothers Medical Problems
- Diabetes
- Heart Disease
- Breast cancer
- Colon cancer
Social History
Who do you live with?*
- Self
- Spouse
- Family
Do you currently smoke?*
- No
- Yes
How much do you smoke?
How many years have you been smoking?
Have you ever smoked?*
- No
- Yes
How many years did you smoke?
What year did you quit?
Occupation
- Retired
For example, Accountant. If retired, please check box and fill in previous profession.
Previous profession:
Immunization Dates
Please list the month/year for each immunization.
Influenza
Shingles (Shingrix)
Shingles (Zostavax)
Hepatitis B
Hepatitis A
Pneumovas
Prevnar 13
Gardisil
Tetanus
TDAP
Screening Male and Female
Screening Male and Female
- Stool Cards
- Colonoscopy
- Bone Density
Male & Female Date - Stool Cards
MM slash DD slash YYYY
Male & Female Date - Colonoscopy
MM slash DD slash YYYY
Male & Female Date - Bone Density
MM slash DD slash YYYY
Was the Male and Female Screening Normal?
- Normal
- Abnormal
Screening Male
Screening Male
- PSA
- Testicular Exam
Male Date - Testicular Exam
MM slash DD slash YYYY
Male Date - PSA
MM slash DD slash YYYY
Was the Male Screening Normal?
- Normal
- Abnormal
Other:
Screening Female
Screening Female
- Pap Smear
- Mammogram
Female Date - Pap Smear
MM slash DD slash YYYY
Female Date - Mammogram
MM slash DD slash YYYY
Was the Female Screening Normal?
- Normal
- Abnormal
Review of Symptoms
General
- Weight Loss
- Weight Gain
- Fever
- Chills
- Fatigue
- Insomnia
HEENT
- Visual changes
- Nose congestion
- Photophobia
- Nose drainage
- Eye itching
- Nose bleeding
- Eye Redness
- Sinus congestion
- Loss of hearing
- Sore throat
- Ear infection
- Hoarse Voice
Heart/Vascular
- Chest Pain
- Rapid heart rate
- Irregular heart rhythm
- Leg swelling
- Pain in the legs when walking
Respiratory
- Shortness of breath
- Coughing
- Wheezing
- Snoring
Breast
- Breast Lumps
- Nipple Discharge
Gastrointestinal
- Stomach pain
- Nausea/vomiting
- Heartburn
- Trouble swallowing
- Diarrhea
- Constipation
- Blood in stool
- Stool incontinence
- Hemmorrhoids
Blood Disorder
- Bleeding disorder
- Easy bruising
- Anemia
Lymphatics
- Enlarged lymph nodes
- Lymphodema
Musculoskeletal
- Joint pain
- Joint swelling
- Muscle pain
- Back pain
- Neck pain
- Fractures
Skin
- Rash
- Hives
- Dry Skin
- Eczema
- Skin Cancer
Nervous System
- Dizzyness
- Spinning
- Numbnes/tingling
- Gait Disturbance
- Balance Difficulties
- Seizures
- Headaches
Psyciatric
- Depression
- Anxiety
- Phobias
- Eating Disorder
- Substance Abuse
Genitorounary
- Burning with Urination
- Frequent Urination
- Nighttime Urination
- Urinary Incontinence
- Blood in the Urine
- Sexual Difficulties
Men
- Difficulties with Urination
- Weak Stream
- Scrotum/Testicular Lump
- STD's
Pre Menopause
- Irregular Menses
- Painful Menses
- Vaginal Discharge
- STD's
Post Menopause
- Vaginal Dryness
- Hot flashes/night sweats
- Vaginal Bleeding
- STDs
Breast
- Breast lumps
- Nipple discharge
Patient Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Social Security Number
Address*
Street Address Address Line 2 City State ZIP Code
Patient Email*
Home Phone
Cell Phone*
Work Phone
What's the best number to reach you?
- Home Phone
- Cell Phone
- Work Phone
Gender
- Male
- Female
Marital Status
Race
- American Indian
- Asian
- Black or African American
- Hispanic
- White
- Pacific Islander
- Do Not Wish To Respond
- Other
Other:
Ethnicity
- Not Hispanic
- Hispanic, Latino
- Do Not Wish To Respond
- Other
Language Preference
- English
- Do Not Wish To Respond
- Other
Other:
Employment Status
- Working
- Student
- Retired
- Disabled
Emergency Contact
Name
First Last
Relationship to Patient
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Primary Insurance
If you do not have insurance, please type in "NONE" to the fields marked required.
Name of Insurance Company*
Claim Address
Street Address Address Line 2 City State ZIP Code
Policy / ID Number*
Group Number
Policy Holder Name*
First Last
Relationship to Patient*
Address
Street Address Address Line 2 City State ZIP Code
Employer
Policy Holder's Social Security Number
Policy Holder's Date of Birth*
MM slash DD slash YYYY
Secondary Insurance
Name of Insurance Company
Claim Address
Street Address Address Line 2 City State ZIP Code
Policy / ID Number
Group Number
Policy Holder Name
First Last
Relationship to Patient
Address
Street Address Address Line 2 City State ZIP Code
Employer
Policy Holder's Social Security Number
Policy Holder's Date of Birth
MM slash DD slash YYYY
Person Responsible for Bills (if different from patient)
Name
First Last
Relationship to Patient
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
How long have you smoked?
Cell Phone
Does Patient Have Living Will or Medical Power of Attorney?
- Yes
- No
If yes, please provide a copy.
File
Max. file size: 100 MB.
I acknowledge that all of the information given is true and correct and that it has been furnished to this office with full knowledge that, regardless of responsible party listed above, the person signing this document is ultimately liable for all said services rendered and that he/she is contractually bound to pay for said services. Further, by signing below, I give Ocotillo Internal Medicine Associates permission to bill my insurance(s) on my behalf.
Patient/Guardian Signature*
Date*
MM slash DD slash YYYY
Email
**PLEASE CHECK IN 15 MINUTES PRIOR TO YOUR APPOINTMENT WITH FORMS COMPLETED**
What medications are you allergic to?
Ocotillo Internal Medicine Associates Financial Agreement
Insurance: Ocotillo Internal Medicine Associates (OIMA) is a primary care practice. Your insurance may require that you select a primary care physician. Failure to do so, prior to the office visit, will result in insurance denying full or partial payment of your claims. A copy of your insurance card is required. We are required by our insurance contracts to collect all co-pays at the time of service. This includes annual visits. Any co-pays not received on the day of the visit will be subject to a $10 processing fee.

It is your responsibility for knowing the benefits of the specific insurance plan(s) you have purchased. OIMA is not responsible for interpreting these benefits, or knowing how your insurance will process your claims. If your insurance requires a referral it is your responsibility to obtain the referral prior to your appointment with specialist, some insurances take a week to process referrals.

Claims Submission: OIMA will file a claim with your insurance company on your behalf. If OIMA is not contracted with your insurance company, you hereby authorize assignment of payment directly to our office for services provided.

Self-Pay Patients: Patients without insurance coverage, or coverage that cannot be verified prior to an appointment, shall be responsible for paying the balance in full at the time services are provided. A $65 deposit prior to the appointment is required (cash or credit card).

Balances: Unless other arrangements have been made in advance, the balance on accounts are due and payable at either the next appointment or upon the receipt of statement whichever is first. It is the patient’s responsibility to update demographic information at each appointment. If an account becomes past due, OIMA will take the necessary steps to collect this debt. After having mailed three statements, a $20 fee will be added to your account balance. If your account is sent to our outside collections agency, OIMA will assess a $40 collection’s fee. There is a $50 NSF fee for any returned checks. An account that is sent to collections may be discharged from our practice.
Patient's Initials*
Insurance: Ocotillo Internal Medicine Associates (OIMA) is a primary care practice. Your insurance may require that you select a primary care physician. Failure to do so, prior to the office visit, will result in insurance denying full or partial payment of your claims. A copy of your insurance card is required. We are required by our insurance contracts to collect all co-pays at the time of service. This includes annual visits. Any co-pays not received on the day of the visit will be subject to a $10 processing fee.

It is your responsibility for knowing the benefits of the specific insurance plan(s) you have purchased. OIMA is not responsible for interpreting these benefits, or knowing how your insurance will process your claims. If your insurance requires a referral it is your responsibility to obtain the referral prior to your appointment with specialist, some insurances take a week to process referrals.

Claims Submission: OIMA will file a claim with your insurance company on your behalf. If OIMA is not contracted with your insurance company, you hereby authorize assignment of payment directly to our office for services provided.

Self-Pay Patients: Patients without insurance coverage, or coverage that cannot be verified prior to an appointment, shall be responsible for paying the balance in full at the time services are provided. A $65 deposit prior to the appointment is required (cash or credit card).

Balances: Unless other arrangements have been made in advance, the balance on accounts are due and payable at either the next appointment or upon the receipt of statement whichever is first. It is the patient’s responsibility to update demographic information at each appointment. If an account becomes past due, OIMA will take the necessary steps to collect this debt. After having mailed three statements, a $20 fee will be added to your account balance. If your account is sent to our outside collections agency, OIMA will assess a $40 collection’s fee. There is a $50 NSF fee for any returned checks. An account that is sent to collections may be discharged from our practice.

Appointments: Patients arriving more than 10 minutes after their appointment time will be asked to reschedule. We require 24 hour advanced notice of cancellation. A $45.00 fee will be applied to your account for short-notice cancellations or missed appointments. A second offense will result in a $90 fee. Patients who miss several appointments without calling may be discharged from our practice.

Annual Exam: Ocotillo Internal Medicine provides comprehensive medical care. As such, an annual appointment is required yearly of every patient. A new patient appointment (initial visit) is considered an annual appointment.

Annual exams at OIMA consist of the preventive portion as well as the assessment or management of specific symptoms or problems, acute and/or chronic. Insurance companies require all services to be itemized and coded appropriately. These codes are standardized and follow commercial insurance and Medicare guidelines. In order to provide you with the optimal medical care and for your convenience we provide these services in one visit. Please understand that because our annual appointments cover both types of services, some fees may be subject to your plan’s co-pay, deductible or coinsurance and it will be your obligation to pay those fees for which OIMA is contractually obligated to collect. If the preventative code is not covered, per your insurance, our office will charge a $65 fee.

Chronic Care Management Services: As part of an ongoing effort to enhance care coordination we are pleased to offer chronic care management services which will help better coordinate your care. Care coordination consists of non-face-to-face care services which Ocotillo will furnish to assist in your care among your different care provider and help you better manage your care. There will no out of pocket cost for this service.
Patient's Initials*
By signing this agreement, you consent to have Ocotillo Internal Medicine Associates bill your insurance monthly for Chronic Care Management services provided to you by providers at Ocotillo Internal Medicine Associates. Please direct questions to our billing office. You may revoke this consent anytime by written request. There will be no out- of-pocket charges for the patient.

BY SIGNING THIS FORM, YOU ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THIS FINANCIAL AGREEMENT.

No changes to this policy by the patient will be acknowledged. Questions may be directed to the billing office.
Patient Name*
First Last
Date*
MM slash DD slash YYYY
HIPAA Consent Form
The Health and Portability and Accountability Act (HIPAA) provides safegaurds to protect your privacy.
List*
Patient Name Date of Birth
Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient hereby waives his/her confidentiality rights should collection action become necessary. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office. However, we are not obligated to alter internal policies to conform to your request.
My protected health information can be released to the following people:
Name Relationship Phone
HIV/AIDS/STD: This form authorizes release of medical information including HIV-related. Confidential HIV-related information is any information indicating that a person has had an HIV-related test, or has HIV infection, HIV-related illness or AIDS, or any information that could indicate a person has been potential exposed to HIV.
My Consent*
- I Consent
- I Do Not Consent
I consent to the release of any positive or negative test result for AIDS/ HIV or STD infection, antibodies to AIDS or infection with any other causative agent of AIDS with the rest of my medical records.
Consent*
Initials - HIV Consent Date
With this consent, I give Ocotillo Internal Medicine permission to call my home or other alternative location provided in patient information form and leave a detailed message on voice mail or in person to someone listed above in reference to any items that assist the practice in carrying out treatment, payment, and health care operations, such as appointment reminders, insurance items and any calls pertaining to my clinical care such as lab and test results.
Patient Signature [or parent, guardian or legal representation]*
Date
MM slash DD slash YYYY
Release of Medical Information
Name
First Last
Date of Birth
MM slash DD slash YYYY
I, (enter name), hereby authorize use or disclosure of protected health information about me.
Ocotillo Internal Medicine
245 S. Dobson Rd.
Chandler, AZ 85224

Phone: 480-895-5870

Fax: 480-895-0573
Dr./Facility
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
I understand that the information used or disclosed may be subject to re-disclosure by the person receiving it and would the no longer be protected by federal privacy regulations.

I may revoke this uathorization by notification in writing of my desire to revoke it. However, I understand that any action taken in reliance on this authorization cannot be reversed, and my recovation will not affect those action. I understand that the provider to whom this authorization is furnished may not condition its treatment or me on whether or not I sign the authorization.

This authorization expires two (2) years from the date of execution.
Today's Date*
MM slash DD slash YYYY
Patient's Digital Signature*
Acknowledgment of Receipt of Privacy Practices
You may refuse to sign this acknowledgment
Signature*
I, have received a copy of this Office's Notice of Privacy Practices.
Date
MM slash DD slash YYYY

Δ

© 2022, Ocotillo Internal Medicine

Our Providers

Physicians
Physician Assistants
Dr. Hackenyos, DO

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Contact Us

T: 480.895.5870
F: 480.895.0573

245 S. Dobson Rd.
Chandler, AZ 85224

3503 S. Mercy Rd.
Gilbert, AZ 85297

Starting in August our office hours will be changing to Mon-Thurs 7:30am-5pm, and phones answered Mon-Thurs 8am-4pm. Our office will be closed on Fridays. This decision has been made to prioritize the well-being of our employees and to promote a healthier work-life balance in order to best service or patients.

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