Dr. Kabir Patient Registration Packet V0.2

Cy-Fair Medical Partners
PATIENT INFORMATION FORM
Dr. Kabir
PHYSICIAN’S NAME
PATIENT’S
FULL NAME
MAIDEN
NAME
APT. #
ADDRESS
CITY
SEX
STATE
F
M
MARITAL
STATUS
SINGLE
MARRIED
OTHER
DATE
OF
BIRTH
)
WORK NUMBER (
)
CELL NUMBER
(
)
PATIENT’S SOCIAL SECURITY #
ZIP
DIVORCED
WIDOWED
PHONE NUMBER (
MM/DD/YY
PATIENT’S
EMPLOYER
EMPLOYER’S
ADDRESS
SPOUSE’S/GUARDIAN’S
NAME
WORK NUMBER
(
)
CELL NUMBER
(
)
DATE
OF
BIRTH
SOCIAL SECURITY #
MM/DD/YY
EMPLOYER
ADDRESS
IN CASE OF
EMERGENCY CONTACT
RELATIONSHIP
PHONE # (
)
PRIMARY
PRIMARY
INSURANCE
INSURANCE COVERAGE
COVERAGE
INSURED’S DOB
INSURANCE
COMPANY
SELF
SPOUSE
PARENT
OTHER
COPAY
AMOUNT
NAME OF
INSURED
INSURED’S
EMPLOYER
INSURANCE
PHONE #
INSURANCE CLAIMS
ADDRESS
CITY
STATE
POLICY
NUMBER
ZIP
INSURED’S SOCIAL SECURITY #
GROUP
NUMBER
SECONDARY
INSURANCECOVERAGE
COVERAGE
SECONDARY
INSURANCE
INSURED’S DOB
INSURANCE
COMPANY
SELF
SPOUSE
PARENT
OTHER
COPAY
AMOUNT
NAME OF
INSURED
INSURED’S
EMPLOYER
INSURANCE
PHONE #
INSURANCE CLAIMS
ADDRESS
CITY
STATE
POLICY
NUMBER
ANY OTHER
INSURANCE COVERAGE
ZIP
INSURED’S SOCIAL SECURITY #
GROUP
NUMBER
YES
NO
COMPANY
NAME
WHOM MAY WE THANK FOR
REFERRING YOU TO OUR OFFICE?
PHONE # (
)
PRIMARY
CARE PHYSICIAN
INSURANCEAUTHORIZATIONANDASSIGNMENT
I authorize Cy-Fair Medical Partners/IMPEL to release to my insurance carrier and/or their agents any information necessary to determine benefits payable for
related services. I authorize the payment of medical benefits to Cy-Fair Medical Partners/IMPEL. I understand that I am ultimately responsible for all services
whether covered by insurance or not. I also authorize my physician, based on his/her discretion, to access my chart for utilization management review.
DATE:
SIGNATURE
form. A-04.New.Patient.12321 Rev. (04/08)
NEW ADULT PATIENT
Name: ___________________________ Date of Birth: __________
If minor, Accompanying Adult’s Name: _______________________
Today’s Date:______________
Please tell us the REASON FOR TODAY’S VISIT or any special concerns you would like to discuss with your
doctor today:
___________________________________________________________________________
___________________________________________________________________________
Please list your CURRENT MEDICATIONS:
Name of Medication
Dosage (ie, milligrams)
How taken (ie, 1 tablet daily)
Please list any ALLERGIES to medications/foods:
Allergy
Type of Reaction (ie, rash, nausea)
Please provide your IMMUNIZATION HISTORY:
Yes
No
Date
Tetanus-Diphtheria Booster
Influenza Vaccine (Flu Shot)
Pneumococcal Vaccine
Tuberculosis (TB) Skin Test
Yes
No
Date
Hepatitis A Vaccine
Hepatitis B Vaccine
Human Papilloma Virus (HPV)
Varicella Vaccine
For Nurse Use Only: Ht__________ Wt__________ Temp ___________ BP ________________ Pulse__________ Resp __________
Pulse ox________ Peak Flow _______________
Please provide your PAST MEDICAL HISTORY:
____ Allergies
____ Anemia
____ Angina (chest pain)
____ Anxiety
____ Arthritis
____ Asthma
____ Atrial fibrillation
____ BPH (enlarged prostate)
____ Blood clots
____ Cancer, type_____________
____ CVA (stroke)
____ COPD (emphysema)
____ CAD (hear disease)
____ Crohn’s disease
____ Depression
____ Diabetes
____ Gallbladder disease
____ GERD (reflux)
____ Hepatitis C
____ High cholesterol
____ High blood pressure
____ Irritable bowel disease
____ Liver disease
____ Migraine headaches
____ MI (heart attack)
____ Osteoarthritis
____ Osteoporosis
____ Peptic ulcer disease
____ Renal disease (kidneys)
____ Seizure disorder
____ Thyroid disease
Please tell us about any SURGERIES you have had, you may indicate the date/year if known:
____ Angioplasty
____ Angioplasty with stent
____ Appendix
____ Arthroscopy knee
____ Back Surgery
____ CABG (open heart surgery)
____ Carpal tunnel release
____ Cataract
____ Cholecystectomy (gallbladder)
____ Cholectomy (colon removed)
____ Colostomy
____ Gastric bypass
____ Hernia repair
____ Hip replacement
____ Knee replacement
____ LASIK
____ Liver biopsy
____ ORIF (repair broken bone)
____ Pacemaker
____ Small bowel resection
____ Thyroidectomy
____ Tonsillectomy
Gender Specific Male:
____ Prostatectomy
____ TURP
____ Vasectomy
Gender Specific Female:
____Breast augmentation
____ Bilateral tubal ligation
____ Breast biopsy
____ Cesarean section
____ D & C
____ Hysterectomy
____ Mastectomy
____Breast reduction
Please list any ADDITIONAL PAST MEDICAL OR PAST SURGICAL HISTORY:
____________________________________________________________________________
ADD/ADHD
Alcoholism
Allergies
Alzheimer’s disease
Asthma
Blood disease
Coronary artery disease (heart disease)
Other
Brother
Sister
Father
Mother
Other
Brother
Sister
Father
Mother
Please provide your FAMILY HISTORY:
Hearing deficiency
High cholesterol
High blood pressure
Irritable bowel disease
Learning disability
Mental illness
Migraines
Obesity
Osteoarthritis
Osteoporosis
Peripheral vascular disease (Blood clots)
Renal (kidney) disease
Seizure disorder
Other:
Premature heart disease (male < 55 yr, female < 65 yr)
Cancer, Type ______________________
CVA (Stroke)
Depression
Developmental delay
Diabetes
Eczema
Please provide your SOCIAL HISTORY:
Do you Smoke?
Yes
No
Former
Type of tobacco: ___________________________
Packs per day: ____________________________
Years smoked: ____________________________
Year Quit: ________________________________
Have you ever tried to quit?
Yes
No
Do you drink Alcohol? Yes
No
Former
Type of alcohol: _____________________________
Frequency: _________________________________
Amount:____________________________________
When was your last drink? _____________________
FOR FEMALES ONLY:
Age at First Period:
Date of Last Menstrual Period:
Date of Last Mammogram:
Date of Last Pap Smear:
Any history of abnormal pap smears?
If Yes, When:
____________
____________
____________
____________
Yes
No
____________
Are periods regular?
Yes
No
Do you have pain with period?
Yes
No
Is Flow:
Light
Spotting
Normal
Heavy
Number of Pregnancies:
Number of Live Children:
Number of Miscarriages:
Number of Abortions:
_______
_______
_______
_______
Cy-Fair Medical Partners
Consent for Treatment
By signing this consent, I am authorizing my physician and/or other individuals he or she
deems appropriate to perform and/or order exams, tests, procedures, and any other care
deemed necessary or advisable for the diagnosis and treatment of my medical condition.
This consent is valid for each visit I make to Cy-Fair Medical Partners unless revoked by
me orally or in writing.
Please be informed Texas law allows a patient to be tested for possible exposure
to the Human Immunodeficiency Virus (HIV), the virus associated with AIDS, in
the following situations: 1) to screen blood, blood products, organs or tissues to
determine suitability for donation; 2) if another individual is accidentally exposed
to a patient’s blood or body fluids, such as through a needlestick (any such test
shall be conducted pursuant to Cy-Fair Medical Partners’ infectious disease
protocol); or 3) if a medical or surgical procedure is to be performed which could
expose health care workers to the patient’s blood or body fluids. This disclosure
is to inform you that you may be tested, at the expense of Cy-Fair Medical
Partners. If any of these situations occur during your treatment period.
____________________________________________
__________________
Patient’s Printed Name
Date of Birth
____________________________________________
__________________
Patient/Legal Representative Signature
Date
_____________________________________________________
Relationship to Patient
_____________________________________________________
Witness
_____________________
Date
form.A-06.Consent.for.Treatment Rev. (04/08)
Patient Name:
DOB:
ePRESCRIBING / PHARMACY SELECTION
Cy-Fair Medical Partners participates with local pharmacies in e-prescribing. This allows your pharmacy of choice to
receive your prescriptions electronically. Your prescriptions can be filled faster, easier, and more efficiently!
Please select your pharmacy of choice from the list provided below, or if not listed, provide it in the space indicated.
12550 Louetta Rd.
 (281) 257-7797
Corner of Louetta & Eldridge
13757 Cypress N. Houston Rd.
 (281) 890-2479
Corner of CNH & Huffmeister
12234 Jones Rd.
 (281) 517-5691
Corner of Jones & Cypress N. H.
11600 FM 1960 West
 (281) 517-7258
Corner of 1960 & Fallbrook
12407 Grant Rd.
 (281) 655-0478
Corner of Grant & Eldridge
12300 Jones Rd.
 (281) 955-5619
Corner of Jones & Cypress N.H.
12445 FM 1960 West
 (281) 477-3792
Corner of 1960 & Eldridge
10965 FM 1960 West
 (281) 890-3346
Corner of 1960 & Jones
 My Pharmacy is not listed above
Pharmacy Name:
Phone Number:
Fax Number:
Zip Code:
Location Type:
 Retail Store Pharmacy
13742 Eldridge Parkway
 (281) 655-8758
Corner of Eldridge & Grant
26270 Northwest Freeway
 (281) 304-9664
Corner of 290 & Cypress Rose Hill
12353 FM 1960 West
 (832) 912-7331
Corner of 1960 & Eldridge
7075 FM 1960 West
 (281) 893-1701
Corner of 1960 & Cutten
 Mail Order Pharmacy
ePrescribing is defined as a physician's ability to electronically send an accurate, error free, and understandable
prescription directly to a pharmacy from the point of care. Congress has determined that the ability to electronically
send prescriptions is an important element in improving the quality of patient care. ePrescribing greatly reduces
medication errors and enhances patient safety. The Medicare Modernization Act (MMA) of 2003 listed standards that
have to be included in an ePrescribe program. These include:
 Formulary and benefit transactions - Gives the prescriber information about which drugs are covered by the
drug benefit plan.
 Medication history transactions - Provides the physician with information about medications the patient is
already taking to minimize the number of adverse drug events.
 Fill status notification - Allows the prescriber to receive an electronic notice from the pharmacy telling them if
the patient's prescription has been picked up, not picked up, or partially filled.
By signing this consent form you are agreeing that Cy-Fair Medical Partners can request and use your prescription
medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes.
Understanding all of the above, I hereby provide informed consent to Cy-Fair Medical Partners to enroll me in the
ePrescribe Program. I have had the chance to ask questions and all of my questions have been answered to my
satisfaction.
Patient Signature
Guardian Signature
Date
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
PATIENT INFORMATION (Please Print):
Name_________________________________ Date of Birth_______________
Social Security Number: ____________________________________________
Address: _________________________________________________________
City: _______________________ State: ____________Zip Code___________
Phone: ___________________________
RELEASE OF MEDICAL RECORDS FROM:
NAME: ____________________________________
TELEPHONE: ______________________________
FAX NO: __________________________________
SEND TO:
Cy-Fair Medical Partners
Attn: _________________
11240 FM 1960 West, Suite 210
Houston, TX 77065
Please send a copy of the following medical records only:
□
□
□
□
□
Lab Reports and Lab Results
Diagnostic Reports
Consultation Reports
Immunization Records
Last Clinic Visit Note
BY MY SIGNATURE I AUTHORIZE RELEASE OF MEDICAL RECORDS
Patient: ______________________________________ Date___________________
CY-FAIR MEDICAL PARTNERS
FINANCIAL POLICY
Thank you for choosing Cy-Fair Medical Partners as your health care provider. We are committed to providing excellent health care
services to you, our patient. As a part of our professional relationship, it is important that you have an understanding of our financial policy.
All patients must read and sign this form prior to receiving services.
™ It is your responsibility to provide us with your most current insurance information.
ª If you fail to provide accurate insurance information in a timely manner, your insurance company may deny the claim. If the claim
is denied, you will be financially responsible for services rendered.
ª We must emphasize that, as medical providers, our relationship is with you, the patient, and not your insurance company. Your
insurance is a contract between you, your insurance company and possibly your employer. It is your responsibility to know and
understand the level of services covered by your insurance company.
ª If you have Medicaid coverage of any kind, you must notify us prior to your visit. This is part of your agreement with Medicaid,
and failure to notify us of Medicaid coverage will result in full financial responsibility for services rendered.
ª We may accept assignment of insurance after verification of your coverage. Please be aware that some or perhaps all of the
services provided may not be covered in full by your insurance company. You are financially responsible for services
not covered by your insurance company.
ª Before receiving services, you must verify that we are participating providers for your insurance company. It is also necessary that
our primary care physician is listed as your primary care provider with your insurance company, if required by your contract with
your insurance company. In the event we are not participating providers or our physician is not listed as your primary care provider
with your insurance company, we will file the initial claim as a courtesy. Payment, however, is due in full at the time of service.
ª We charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s
arbitrary determination of usual and customary rates.
ª Copayments, coinsurance and/or deductibles are due at the time of service. We will estimate the amount you owe based on
information we receive from your insurance company. However, you are responsible for paying the full amount determined by
your insurance company once they have paid your claim – regardless of our estimation.
ª It is your responsibility to provide us with your most current billing information.
ª You must provide your most current billing address, all available telephone numbers and any other important contact information.
If your address or contact information changes, it is your responsibility to contact us with the updated information.
ª We will send a statement (to the billing address you provide) notifying you of any balances you may owe. If you have any
questions or dispute the validity of this balance, it is your responsibility to contact our business office within 30-days after receipt
of the initial statement. You can call (817)514-5200 or 1-800-555-1429.
ª Payment in full is due upon receipt of the statement. Patient balances not paid in full within 30 days of the statement
issue date are deemed past due. Past due accounts may be subject to a $5.00 monthly late fee and may be referred to a
professional collection agency and/or attorney for further collection activity. You will be responsible to pay all collection
costs incurred, including attorney’s fees and court costs if applicable.
ª If you are not able to pay the balance due in full, you must contact our billing office to discuss a payment schedule. Any late fees
already incurred on past due balances will be included in any mutually agreed upon arrangements. If you fail to make payments as
agreed upon, your account may be referred to a professional collection agency and/or attorney. You will be responsible for all
collection costs incurred, including attorney’s fees and court costs if applicable.
ª If your account is assigned to a professional collection agency, you will be notified by certified mail that you will no longer be able
to receive services from any of the physicians at Cy-Fair Medical Partners. Failure to accept this certified letter (and/or to pick it up
at the post office) serves as notice of termination of services.
ª In the event you submit payment by check and the bank returns the check unpaid for any reason, we will add $25.00 to your
original balance. In addition, we may seek all additional legal remedies provided to us under Texas law.
ª We may charge you a “No Show” fee if you fail to cancel or reschedule your appointment at least 24 hours prior to your
appointment date.
ª Failure to keep your account balance current may require us to cancel or reschedule your
appointment.
Full payment is due at the time of service. We accept cash, checks and credit cards. I have read and understand this Financial Policy.
Signature of Responsible Party
Patient Name: ___________________________
CFMP.Financial.Policy.doc
Date
Patient Date of Birth: ___________________________
EPM Medical Record Number: _________________________
NOTICE OF PRIVACY PRACTICES (NPP) ACKNOWLEDGEMENT
A Notice of Privacy Practices (NPP) is provided to all patients. This Notice of Privacy Practices
identifies: 1) how medical information about you may be used or disclosed; 2) your rights to access
your medical information, amend your medical information, request an accounting of disclosures of
your medical information, and request additional restrictions on our uses and disclosures of that
information; 3) your rights to complain if you believe your privacy rights have been violated; and
4) our responsibilities for maintaining the privacy of your medical information.
The undersigned certifies that he/she has read the foregoing, received a copy of the Notice of Privacy
Practices and is the patient, or the patient’s personal representative.
_______________________________________ ________________________________________
Name of Patient
Signature of Patient
_________ / _________ / _________
Date Signed
_______________________________________ ________________________________________
Name Patient’s Personal Representative
Signature of Patient’s Personal Representative
_________ / _________ / _________
Date Signed
________________________________________________________________________________
FOR INTERNAL USE ONLY
_______________________________________ ________________________________________
Name of Employee
Signature of Employee
If applicable, reason patient’s written acknowledgement could not be obtained:
 Patient was unable to sign.
 Patient refused to sign.
 Other _________________________________________________________________________
_________________________________________________________________________
Version 3 August 2013 (Notice Dated: As noted on NPP)
09/ 23/ 2013 (Date: As noted on NPP)