LPMP Respiratory Disease Consultants
Transcription
LPMP Respiratory Disease Consultants
LPMP Respiratory Disease Consultants 270 S. Collins RD., Ste.#300 Sunnyvale, Tx 75182 6701 Heritage Pkwy., Ste.#150 Rockwall, Tx 75087 Phone: 972-285-5675 Fax: 972-698-8843 Patient Information Please provide us with your insurance and valid ID PATIENT’S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTHDATE SEX DRIVER’S LICENSE NUMBER STATE ISSUED MALE FEMALE PLACE OF BIRTH CITY_______________________ STATE_______ PATIENT’S BILLING/MAILING ADDRESS PATIENT’S PHYSICAL ADDRESS STREET OR PO BOX STREET ADDRESS CITY STATE COUNTRY USA OTHER __________ ZIP COUNTY CITY STATE ZIP COUNTY COUNTRY USA OTHER __________ PATIENT’S CONTACT INFORMATION HOME PHONE # DAY PHONE # ALTERNATE PHONE E-MAIL ADDRESS PATIENT’S EMERGENCY CONTACT INFORMATION NAME ADDRESS RELATIONSHIP CONTACT PHONE NUMBER PATIENT’S ADDITIONAL INFORMATION MOTHER’S MAIDEN NAME ETHNICITY HISPANIC NON-HISPANIC UNKNOWN RACE ASIAN PACIFIC ISLANDER BLACK NATIVE AMERICAN OTHER UNKNOWN WHITE MARITAL STATUS ANNULLED POLYGAMOUS DIVORCED INTERLOCUTORY LEGALLY SEPARATED LIFE PARTNER MARRIED SINGLE UNKNOWN WIDOWED LANGUAGE ENGLISH SPANISH OTHER __________ STUDENT STATUS FULL-TIME NOT A STUDENT PART-TIME RELIGION CHURCH VETERAN YES NO REFERRING PHYSICIAN PRIMARY CARE PROVIDER/PHYSICIAN NAME STREET ADDRESS CITY, STATE, AND ZIP OFFICE PHONE NUMBER FAX NUMBER NAME STREET ADDRESS CITY, STATE, AND ZIP OFFICE PHONE NUMBER FAX NUMBER SMOKER YES NO RESPONSIBLE PARTY’S INFORMATION (if different than above) NAME (Last, First, Middle) SSN PREVIOUS LAST NAME BIRTHDATE SEX NICKNAME RELATIONSHIP TO PATIENT RESPONSIBLE PARTY’S BILLING/MAILING ADDRESS RESPONISBLE PARTY’PHYSICAL ADDRESS STREET OR PO BOX STREET ADDRESS CITY HOME PHONE NUMBER REV. 09292014 STATE ZIP CITY E-MAIL ADDRESS STATE ZIP LPMP Respiratory Disease Consultants 270 S. Collins RD., Ste.#300 Sunnyvale, Tx 75182 6701 Heritage Pkwy., Ste.#150 Rockwall, Tx 75087 Phone: 972-285-5675 Fax: 972-698-8843 Patient Information Please provide us with your insurance and valid ID PATIENT’S EMPLOYER EMPLOYER’S ADDRESS (Street, City, State and Zip) LOCAL ADDRESS CORPORATE ADDRESS COUNTY TYPE OF BUSINESS OCCUPATION NAME OF EMPLOYER EMPLOYMENT STATUS FULL-TIME PART-TIME WORK PHONE RETIRED DISABLED PRIMARY INSURANCE NAME OF SUBSCRIBER (Last, First, Middle) RELATIONSHIP TO PATIENT SUBSCRIBER’S ADDRESS (Street, City, State and Zip) POLICY NUMBER SUBSCRIBER’S SOCIAL SECURITY NUMBER SUBSCRIBER’S DATE OF BIRTH NAME OF INSURANCE COMPANY GROUP NUMBER ADDRESS OF INSURANCE COMPANY (Street, City, State, and Zip) EFFECTIVE DATE EXPIRATION DATE SECONDARY INSURANCE (if applicable) NAME OF SUBSCRIBER (Last, First, Middle) RELATIONSHIP TO PATIENT SUBSCRIBER’S ADDRESS (Street, City, State and Zip) POLICY NUMBER SUBSCRIBER’S SOCIAL SECURITY NUMBER SUBSCRIBER’S DATE OF BIRTH NAME OF INSURANCE COMPANY GROUP NUMBER ADDRESS OF INSURANCE COMPANY (Street, City, State, and Zip) EFFECTIVE DATE EXPIRATION DATE ASSIGNMENT AND RELEASE I, the undersigned, have insurance with _______________________________________ and assign directly to Dr. _______________________ all medical benefits. I understand that I am financially responsible for all charges incurred. A copy of the back and front of my insurance card is required for billing purposes. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all my insurance submissions. Sometimes healthcare information may be used for research, all such information is anonymous, and patient confidentiality is maintained. If you do not want any information to be used for research please check here ______. Signature of Insured _____________________________________________________________ Date ___________________________ CONSENT FOR TREATMENT I, the undersigned hereby authorize and give consent to Dr. ________________________ for any x-rays examinations, laboratory tests, and treatment rendered to the patient named above. Signature ______________________________________________________________________ Date ___________________________ MEDICARE AUTHORIZATION I request the payment of authorized Medicare benefits be made directly to me or the physician rendering services. Coinsurance and deductibles are based upon the charge determination of the Medicare carrier. Signature _______________________________________________________________________ Date __________________________ Please be advised, it is the patient’s responsibility to ensure that the physician they see is contracted with their insurance plan. REV. 09292014 Respiratory Disease Consultants 270 Collins Rd., Ste.#300 Sunnyvale, Tx 75182 6701 Heritage Pkwy., Ste.#150 Rockwall, Tx 75087 Office: (972) 412-6969 Fax: (972) 412-6639 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 to made Respiratory Disease Consultants 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 needle stick (any such test shall be conducted pursuant to Respiratory Disease Consultants infectious disease protocol); or 3) if a medial or surgical procedure is to be performed which could expose health care workers to the patient’s blood or bodily fluids. This disclosure is to inform you that you may be tested, at the expense of Respiratory Disease Consultants 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:______________________ Lake Pointe Medical Partners Respiratory Disease Consultants Adult Medical History Name: _________________________________________________________________________ Today’s Date: ______/_______/ (Last) (First) (Middle) Date of Birth: ______/______/______ Age: Reason for Todays Visit?: Referring Physician: (Name) (Phone number) PREFERRED PHARMACY: NAME OF PHARMACY ADDRESS AND PHONE NUMBER OF PHARMACY LOCAL MAIL ORDER - 1. Please List any Medication allergies and Reaction (use back of paper if needed) Medication Reaction 2. Current Medications (including dosage and frequency) (You may use the back of this form for additional medications) Medication Dosage Frequency 3. 4. 5. 6. 7. 8. 10. Please list any recent discontinued medications: ________________________________________________ Have you been a smoker?_____(Y or N), if so, state when active or when quit. __________________________ Do you use alcohol?____(Y or N) If yes, please circle correct response: Heavily Occasionally Quit Yr_____ Have you used illegal IV drugs either now or in the past?____ (Y or N) If yes state when stopped. What is your occupation? _____________ Have you been exposed to irritants in your occupation?____(Y or N) Are you retired?____(Y or N) 9. Are you disabled?____(Y or N) Is there any history of: (Y or N) Diabetes____ Emphysema____ Asthma____ Allergies____ Heart Disease____ Hypertension____ Cancer____ 11. Surgery History (example: Tonsils, appendix, gallbladder) _______________________________________ 12: Chronic Conditions and dates of treatment:(example: COPD 1/1/13 (this should include lung disease): 13. Please list the last date of chest Xray and do you know the diagnosis of that X-ray, if so please list: ___/____/____ Finding: ____________________________________________________________________ 14. Your main complaint today: Shortness of Breath____ Cough____ Chest discomfort/pain____ Allergy Problem____ Sleep Problem____ Abnormal Chest X-ray____ 15. Are you having problems with: Fever___ Weakness___ Sore Throat___Hoarseness___Sinus Congestion___ Severe Depression___ Anxiety___ Muscle Pain___ Joint Pain___Chills___Fatigue___ Weakness___ Swelling of your ankles or legs___Rashes___Passing Out___ Burning w/urination___Loss of urine involuntary___ Lack of appetite___Fast heart beat___Problem breathing while laying flat___ Constipation___ Numbness___Weight Gain___ Weight Loss___Nausea___Vomiting __ Unable to Swallow___Stomach Pain___Diarrhea___ Visual Problems___ Noticed any enlarged lymph nodes___ 16.Last Hospitalization:____/____/______ Reason for Hospitilization: Respiratory Disease Consultants 270 South Collins Rd., Ste. #300 Sunnyvale, Tx 75182 6701 Heritage Pkwy., Ste.#150 Rockwall, Tx 75087 Office: (972) 285-5675 Fax: (972) 698-8843 Financial Policy Thank you for choosing Respiratory Disease Consultants as your health care provider. We are committed to providing excellent health care services to you, our patients. As a part of our professional relationship, it is important that you have an understanding 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. > If you fail to provide accurate insurance in a timely manner, your insurance company may deny the claim. If the claim is denied, you will be financially responsible for the services rendered. We must emphasize that, as a 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. > 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. > We may accept assignment of insurance after verification of your coverage. Please be aware that your insurance company may not cover some or perhaps all of the services provided in full. You are financially responsible for services not covered by your insurance company. > Before receiving services, you must verify that we are participating providers for your insurance company. In the event we are not participating providers with your insurance company, we will file the initial claim as a courtesy. Payment, however, is due in full at the time of service. > 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. > 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. + It is your responsibility to provide us with your most current billing information. > You must provide your most current billing address, all available telephone numbers and any important contact information. If your address or contact information changes, it is your responsibility to contact us with the updated information. > We will send a statement (to the billing address you provide) notifying you of any balance you may owe. If you have any questions or dispute a 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 (972)285-5675. > 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. > 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 to a professional collection agency and/or attorney. You will be responsible for all collection costs incurred, including attorney fees and court cost if applicable. > 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 form any of the physicians at Respiratory Disease Consultants. Failure to accept this certified letter (and/or to pick it up at the post office) serves as notice of termination of services. > 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. > 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. > 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 the Financial Policy. Signature of Responsible Party Patient Name: Date Patient Date of Birth: Respiratory Disease Consultants Acknowledgement of Receipts Notice of Privacy Practices I have been provided with a Notice of Privacy that provides me a more complete description of the uses and disclosures of certain health information. I understand Respiratory Disease Consultants reserves the right to change their Notice of Privacy Practice and prior to implementation will provide an updated Notice of Privacy Practice and prior to implementation will provide an updated copy in the physician’s office. I may request a copy of the updated Notice of Privacy Practices by calling my physician’s office or requesting a copy in person at my appointment. Patient’s Printed Name Date of Birth Patient/Legal Representative Signature Date Relationship to Patient ________________________ Witness Date I wish to be contacted in the following manner: Home Telephone: (choose one) ____ Ok to leave a message with detailed information ____ Leave message with call-back number only Phone: (choose one) ____ Ok to leave a message with detailed information ____ Leave a message with Call-back number only The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for Respiratory Disease Consultants to share my protected health information with anyone listed below: Name Relationship Name Relationship Name Relationship Notice of Privacy Practices (NPP) Acknowledgement A NOTICE OF PRIVACY PRATICES (NPP) is provided to all patients. This is 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 Patients Personal representative Name of Patient Signature of Patient ______/______/ Date Signed Name of 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) Respiratory Disease Consultants 270 South Collins Rd., Ste.#300 Sunnyvale,Tx 75182 6701 Heritage Pkwy., Ste #150 Rockwall, Tx 75087 (p)972-285-5675 (f)972-698-8843 Important PATIENT INFORMATION NOTICE Physician office compliance with Red Flag Rule The Federal Trade Commission (FTC), in conjunction with other agencies, published the Red Flag Rules defining what a creditor and financial institution must do to implement an Identity Theft Program. The Red Flag Rules require those covered, including medical practices, to identify at-risk accounts and to define, detect, and respond to Red Flags in order to prevent or mitigate identify theft. Medical Identity theft happens when a person seeks health care using someone else’s name or insurance information. We are committed to protecting your identity and have developed a compliance policy that will help us protect your vital personal information. Beginning October 1, 2010, our staff will be asking patients and/or guardians to provide the following at each appointment: Photo ID (Driver License, Passport, Employment picture ID) Current Insurance card Verification of patient demographics, including phone number and email address. Please Note: No one, including minors, will be permitted to use a Medical –Flex Card, major credit card, or make a payment by check if the patient name does not match the form of payment used- UNLESS we have written permission from the payer. We have a form available for the person named on the card or check to complete, sign and returned to our office. The form provides permission for the specifically named patient to use that payment type for the required payments needed. This form will only need to be completed once. Please remember that this is being instituted for your protection Respiratory Disease Consultants is committed to protect our patients through the highest-level quality of care and unparalleled services. Thank you for your assistance in helping us comply with our Identity Theft Program. If you would like a complete copy of the Red Flag Rules, please ask the receptionist and she will be happy to provide you with a copy. Patient name Signature Line Patient Date of Birth Date Respiratory Disease Consultants 270 South Collins Rd., Ste.#300 Sunnyvale, Tx 75182 6701 Heritage Pkwy., Ste.#150 Rockwall, Tx 75087 Office: (972)285-5675 Fax: (972)698-8843 Preliminary Sleep Questionnaire 1. Have you been gaining weight within the last 1-2 years? ___Y___N 2. Are you aware of have you been told you snore? ___Y___N 3.If Yes, has it been getting worse ___Y___N 4.Do you consider your sleep disturbed? ___Y___N 5.Do you have fatigue during the day? ___Y___N 6.Do you fee sleepy during the day? ___Y___N 7.Do you fall asleep during the day? ___Y___N 8. Do you have trouble waking up in the morning? 9. How many times to you wake up at night? 10.How More__ many times do you get out of bed ___Y___N 1 2 3 4 5 More__ at night?1 2 3 4 11.Do you wake feeling short of breathe at night? ___Y___N 12.Do you often wake up with headaches? ___Y___N 13.Do you have significant problems with: Depression Yes or No Anxiety Yes or No Muscle Tension Yes or No 14.Do you take medicine regularly for: Asthma Yes or No COPD Yes or No Insomnia Yes or No Arthritis Yes or No Back Pain Yes or No CHF(Congestive Heart Failure) Yes or No 15.Do you have parents or siblings that have been diagnosed with Sleep Apnea? Yes or No 16.Do you drink more than 3 caffeinated drinks a day? Yes or No- If so how many? 17. Do you drink alcohol every day? Yes or No 18.What is your bed partner’s main complaint about your sleeping habits: List Below 5