The GorillaBill.com Better Health Toolkit™
The Better Health Toolkit™ includes patient forms that will help you manage your health care, Save money and Protect your health. The patient forms can be downloaded to your computer so that you can complete it, email it to your provider and easily update it as needed.
Manage Your Care – Keep track of critical documents such as medical records, test results, discharge instructions, receipts and health history. Managing your records helps protect you and improves service from your provider.
Save Money – Having vital information at your fingertips saves you money. Avoid duplicate or unnecessary medical tests, compare your bills and insurance statements to the services you received, and track tax-deductible medical expenses.
| Protect Your Health - | |
 | Symptoms Checklist and Health History facilitate accurate diagnosis |
| Daily Medical Journals help patients keep a record of medications and results |
| Keep track of questions and concerns so that you are prepared for your next doctor visit |
| Alert providers to potential drug interactions and allergies |
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| Form Name | Description | Form Sample |
| Authorization for Release of Health & Medical Info - General | It is your right as a patient to obtain copies of your medical records. Use this form to request copies of your records from your health care provider. If you have to switch providers due to an insurance change or a move, your new provider will be able to quickly see your health history. If you need to dispute a charge on your medical bills, keeping a file of your provider health records will save you money and time. |  |
| Authorization for Release of Health & Medical Info – Detailed | GorillaBill.com members are offered two forms to use for requesting the release of their health and medical records. This detailed form may be of greater use for requesting hospital records and similar documents. Keep both forms in your Better Health Toolkit ™ and ask your providers which one they prefer. |  |
| Emergency – Contact Information | Guarantee that your providers & friends know whom to contact in case of an emergency. Update this form when any changes occur, keep a copy in your GorillaBill.com Better Health Toolkit™ and give a copy to your providers, family members, friends or neighbors. |  |
| Family Health History Report | Knowing your family health history helps your providers make treatment decisions. Make the most of this report and ask relatives to help you fill it out. Keep a copy in your GorillaBill.com Better Health Toolkit™ and review it with your health care professional to develop disease prevention strategies that are right for you. If you know your inherent risk factors, you can begin tests or treatments even before any disease is evident. Your family's history can also help identify other members of your family who may be at risk of developing certain conditions. |  |
| Fees for Provider Services – Request Form | Become a better Consumer of Health Care! Why put yourself in a position to pay out of pocket for services that may not be fully covered by your health insurance plan? Use this form to get the information that allows you to make the best decision for your health and your health care dollars.
Keep a copy of this form in your GorillaBill.com Better Health Toolkit™ and use it when you are uncertain of your health insurance coverage for specific services or procedures. A representative at your provider's office can complete this form with the procedure name, code and the fee they charge. Once you check your coverage for that service, you can make an informed decision with your provider. |  |
| Health Care Provider Contact Sheet | Keep all of your health care providers' contact information on one easy-to-access form. If you need to contact them in an emergency, request more information from the billing department, or your primary care doctor needs to speak to your specialty provider, you and your caretaker will have the information at your fingertips. Keep this form up-to-date and place a copy in your GorillaBill.com Better Health Toolkit™ for convenient access. |  |
| Hospital Treatment Journal | If you're in the hospital and feel you are able, keep your own record of major tests, treatments, and medications. If you don't feel well enough, ask a friend or relative to keep a log. Even a limited record of what was done on each day can make it easier to decipher the bills and review for errors and overcharges. |  |
| Medication Journal | Have you ever wondered if you already took your medicine or supplements that day? Whether you need to keep track of a new medicine or you are managing several medications and supplements, this journal will help you organize and assure that the correct doses are taken. List any reactions you had to the medication to share with your doctor on your next visit. This journal is also a valuable tool for individuals who have multiple caretakers. |  |
| Medication List | Keep track of your medications, natural remedies and supplements in one organized list . Many prescription medications can have severe interactions with over-the-counter drugs and natural remedies. It is vital that your health care provider know exactly what you are taking, how often and how much. Keep this list up to date in your GorillaBill.com Better Health Toolkit™ and bring a copy with you when you visit your health care providers. |  |
| Minor – Medical Release to Treat | Take every precaution to protect your children's health while they are with a caretaker. Whether your child is at school, camp or visiting relatives, this medical release will help your caretaker authorize treatment during an emergency. It is beneficial to have a medical release on file in your child's school and at your doctor's office, as well as the nearest hospital, just to be sure there is no delay in treatment. This information should be updated annually. |  |
| Nutrition Checklist – for Older Adults | Determine your nutritional score with this checklist adapted from the Nutrition Screening Initiative project of the American Academy of Family Physicians, American Dietetic Association, and the National Council on Aging. These nine questions will help you compile the important information about your nutrition, your eating habits and any nutritional risks. Bring it with you to show your doctor and complete a new checklist every 6 months. |  |
| Patient Rights and Responsibilities Statement | This simple statement of Rights and Responsibilities will ensure that both Patient and Health care Provider have a common understanding of expectations and receive the greatest return on their valuable investment of time. Keep a copy in your GorillaBill.com Better Health Toolkit™ and bring it with you to your health care visits to assist in the development of a strong patient – provider relationship. |  |
| Pediatric - Annual Health Exam Report | Your child's annual health and wellness exam helps your pediatrician track their development. Parents often receive brief notes as to the child's measurement and growth percentile, but rarely keep record of their health changes year to year. Bring this report to your child's exam and record his or her fundamental health information each time. This form can be used in conjunction with the US Growth Charts and the Pediatric Health Tracking Chart. |  |
| Pediatric - Birth & Family Health History | Personally maintaining a health history record for your child will save you valuable time in the pediatrician's office plus guarantee better and more accurate treatment for your son or daughter. Keep this completed form on file with your pediatrician as well as any specialty providers. In doing so, your physicians will have the information they need to best assess your child's health and create a plan for preventative health measures. |  |
| Pediatric - Health Tracking Chart | It is difficult to keep track of children's health history from memory alone, whether it involves the onset of allergies or reactions to immunizations; ear infections; changes in eyesight or hearing or other health care concerns. This recording can be vital to your child's health. A simple tracking chart can help you note these occurrences and provide accurate, up-to-date information you and your doctor may need to provide the best health care for your children. |  |
| Personal & Insurance Information | Keep all of your important health insurance data on one easy-to-read form. Place a copy of this completed form in your GorillaBill.com Better Health Toolkit™ for easy access to your plan information and the numbers you and your provider need to make informed decisions regarding which services and procedures are covered by your insurance plan. |  |
| Personal Health History Report | Take an active role in your own health care by summarizing and personally keeping track of your health history and medical information. This brief report will not only assist your providers by knowing more about your past health experiences, it allows them to calculate and manage the risks of passing certain conditions to your children. Keep a current copy of your report in your GorillaBill.com Better Health Toolkit™ for quick reference. |  |
| Questions to ask your Provider | It's amazing how quickly a question can be forgotten when you feel nervous or distracted at the doctor's office. Having a list of questions to ask your health care provider will assist you in receiving the answers you need, without feeling rushed through your appointment. Keep a copy of this list in your GorillaBill.com Better Health Toolkit™ and bring it with you to your provider visit. Asking questions and taking notes during your visit will help you better manage your health. Good health care starts with good communication between you and your provider. |  |
| Symptom Checklist | Health care symptoms need to be noted and brought to the attention of your health care provider. Use this form to prepare for your doctor visit by listing your current symptoms and the frequency in which they are occurring. The few moments it takes to fill in a brief check list can help your provider diagnose a medical condition, decide what medical tests to run, and determine whether you may benefit from preventative measures to lower your risk of a specific disease. |  |
| US Growth Chart: boys 0-36 mths old | Recording your child's development gives you peace of mind that your child is growing and developing in accordance with others in their age group. Choose one of these four clinical charts, designed by the Center for Disease Control, based on your child's age and sex. You can record your own data and update it when you visit your pediatrician. Any concerns you have about your child's development should be discussed with your pediatrician. [Percentile Curves found on these charts represent what percentage of children are of the same weight or height (stature). The median weight or height listed for each age group is represented as the 50% percentile, meaning that 50% of children will be above this mark and 50% will be below it.] |  |
| US Growth Chart: boys 2-20 years old | Recording your child's development gives you peace of mind that your child is growing and developing in accordance with others in their age group. Choose one of these four clinical charts, designed by the Center for Disease Control, based on your child's age and sex. You can record your own data and update it when you visit your pediatrician. Any concerns you have about your child's development should be discussed with your pediatrician. [Percentile Curves found on these charts represent what percentage of children are of the same weight or height (stature). The median weight or height listed for each age group is represented as the 50% percentile, meaning that 50% of children will be above this mark and 50% will be below it.] |  |
| US Growth Chart: girls 0-36 mths old | Recording your child's development gives you peace of mind that your child is growing and developing in accordance with others in their age group. Choose one of these four clinical charts, designed by the Center for Disease Control, based on your child's age and sex. You can record your own data and update it when you visit your pediatrician. Any concerns you have about your child's development should be discussed with your pediatrician. [Percentile Curves found on these charts represent what percentage of children are of the same weight or height (stature). The median weight or height listed for each age group is represented as the 50% percentile, meaning that 50% of children will be above this mark and 50% will be below it.] |  |
| US Growth Chart: girls 2-20 years old | Recording your child's development gives you peace of mind that your child is growing and developing in accordance with others in their age group. Choose one of these four clinical charts, designed by the Center for Disease Control, based on your child's age and sex. You can record your own data and update it when you visit your pediatrician. Any concerns you have about your child's development should be discussed with your pediatrician. [Percentile Curves found on these charts represent what percentage of children are of the same weight or height (stature). The median weight or height listed for each age group is represented as the 50% percentile, meaning that 50% of children will be above this mark and 50% will be below it.] |  |
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