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