PATIENT INFORMATION FORM (PLEASE PRINT)
DATE:«CurrentDate» TIME: «CurrentTime»
PATIENT INFORMATION
Social Security No. «PatientSSN»
Patient Name «PatientFullName»
Sex: «PatientSex»
Date of Birth «PatientDOB»
Marital Status: Single, Married, Divorced, Widowed, Legally Separated (circle one)
Race: Caucasian/White, Latino/Hispanic, Black or African American, American Indian or Alaskan Native, Asian, Native Hawaiian or Other Pacific Islander, Other, Not Reported/Refused (circle one)
Ethnicity: Caucasian/White, Latino/Hispanic, Black or African American, Other, Not Reported/Refused (circle one)
Language: English, French, Spanish, Chinese, Japanese, Korean, Sign Language, Vietnamese, Other (circle one)
Employment Status: Employed, Unemployed, Self Employed, Disabled, Retired, Full-time Student, Part-time Student (circle one)
Employer: ______Occupation ______
Patient Mailing Address ______City ______State _____ Zip ______E-mail Address ______
Home Phone ______Cell Phone ______
Work Phone ______Referring Physician (Include Phone No.) ______
By including your cell phone number, you have given Premier consent to call your cell phone for appointment reminders using our automated system.
Other Current Healthcare Providers (Include Phone No.)
Primary Care ______Cardiology ______
Pulmonary ______Endocrinology ______
Nephrology ______Dialysis Center ______
INSURANCE INFORMATION
PRIMARY Insurance Company ______Group No. ______Member ID ______
Specialist Office Co-pay Amount ______Subscriber's Social Security No. ______
Primary Insurance Subscriber: Patient, Other (circle one)
Subscribers Name (First, Middle, Last) ______Sex: M F (circle one)
Date of Birth ______Marital Status: Single, Married, Divorced, Widowed, Legally Separated (circle one)
Employment Status: Employed, Unemployed, Self Employed, Disabled, Retired, Full-time Student, Part-time Student (circle one)
age 1 of 5 08/2010
PATIENT INFORMATION FORM, CONTINUED
«PatientFullName» «PatientNumber»
Subscribers Employer ______
Subscribers address (if different from patient) ______City ______State ____ Zip ______
Subscribers Home Phone ______Cell Phone ______Work Phone ______
Patient Relationship to Subscriber: Self, Child, Wife, Husband, Parent, Other (circle one)
SECONDARY Insurance Company ______Group No. ______Member ID ______
Specialist Office Co-pay Amount ______Subscriber's Social Security No. ______
Secondary Insurance Subscriber: Patient Other (circle one)
Subscribers Name (First, Middle, Last) ______Sex M F (circle one)
Subscriber's Date of Birth ______Marital Status: Single, Married, Divorced, Widowed, Legally Separated (circle one)
Employment Status: Employed, Unemployed, Self Employed, Disabled, Retired, Full-time Student, Part-time Student (circle one)
Subscribers Employer ______
Subscribers address (if different from patient) ______
City ______State ____ Zip ______
Home Phone ______Cell Phone ______Work Phone ______
Patient Relationship to Subscriber: Self, Child, Wife, Husband, Parent, Other (circle one)
WORKERS COMPENSATION or AUTO INSURANCE INFORMATION
Your Supervisor ______Supervisors Phone No. ______
Workers Compensation or Auto Insurance Phone No. ______
Claims Address ______City ______State ______Zip ______
Adjusters Name ______Adjusters Phone No. ______
Claim No. ______Approval No. ______
Date of Injury ______Did injury occur at work: Y N (circle one) Auto Accident: Y N (circle one)
Briefly describe injury or accident ______
Page 2 of 5 08/2010 NEW PATIENT INFORMATION FORM, CONTINUED
EMERGENCY CONTACT INFORMATION
«PatientFullName» «PatientNumber»
Contact Name (First, Middle, Last) ______Sex: M F (circle one)
Language: English, French, Spanish, Chinese, Japanese, Korean, Sign Language, Vietnamese, Other (circle one)
Home Phone ______Cell Phone ______Work Phone ______
Patient Relationship to Contact: Child, Wife, Husband, Parent, Grandparent, Other (circle one)
Contact is a Parent/Guardian: Y N (circle one) If patient is under the age of 18, Emergency Contact should be a Parent or Guardian unless patient is an Emancipated Minor.
PHARMACY
Patient's Preferred Pharmacy ______Phone No. ______
Pharmacy Address ______City ______State ____ Zip ______
CONSENTS
Do you have any of the following:
Living Will, Do Not Resuscitate (DNR), Power of Attorney, End of Life Decision, No Cardio-Pulmonary Resuscitation (CPR), None (circle any that apply)
List names of anyone you give us permission to release your medical information to, their relationship to you and phone no.
______
______
May we leave a message for you on your phone at: home, work, cell (circle all that apply)
Page 3 of 5 08/2010
PATIENT HISTORY
«PatientFullName» «PatientAge» «PatientDOB»
Reason for visit:______
Patient Past Medical History
No Prior Serious Illness
Musculoskeletal
EndocrineY N Arthritis
Y N DiabetesY N Gout
Y N Thyroid DisordersY N Lupus
Y N Hyperlipidemia (High Cholesterol)Y N Fibromyalgia
EyesBreast
Y N GlaucomaY N Breast Cancer
Y N Legally BlindY N Skin Cancer
Y N Scleroderma
Cardiovascular
Y N High Blood PressureNeurologic
Y N Congestive Heart FailureY N Stroke
Y N Prior Heart AttackY N Seizure Disorder, Epilepsy
Y N Cardiac CatherizationY N Brain Aneurysm
Y N Coronary Artery DiseaseY N Neuroloathy (Weakness in hands/feet)
Y N Previous Hospitalization for Cardiac Problem
Y N Non healing woundHematologic/Lymph
RespiratoryY N Blood Clots
Y N AsthmaY N Anemia
Y N EmphysemaY N HIV Infection
Y N BronchitisY N Hodgkin’s Disease
Y N PneumoniaY N Leukemia
Y N TuberculosisY N Lymphoma
Y N Shortness of breath
Y N Sleep ApneaSocial History
GIY N Alcohol Use Frequency____
Y N Diverticulitis of Colon (Inflamed Colon)Y N Caffeine Use
Y N Colonic Diverticulosis Y N Drug Use Y N Gastroesophageal reflux disease (GERD) Y Current every day smoker
Y N Colon CancerY Current some day smoker
Y N HepatitisY Former Smoker
Y N Ulcerative ColitisY Never smoked
Y N Crohn’s DiseaseY Smoker, current status unknown
Y N CirrhosisY Unknown if ever smoked Y N Hiatal Hernia Y N Tobacco Use
Y N Irritable Bowel Syndrome
Family History
GUY N Heart Disease
Y N Kidney StonesY N High Blood Pressure
Y N Prostate TroubleY N Diabetes
Y N DialysisY N Stroke
Y N Kidney FailureY N Colon Cancer
Y N End Stage Kidney Disease Y N Breast Cancer
Y N Renal dialysis status hemodialysis
Past Surgical HistoryGI
ArterialY N Appendectomy
Y N Aneurysm Repair (AAA)Y N Gallbladder Surgery
Y N Previous Coronary Artery BypassY N Partial Colectomy (Colon Resection)
Y N Leg BypassY N Colostomy (Ostomy Bag)
Y N Peripheral Stent (Leg or Trunk Stent)Y N Ileostomy (Intestine)
Y N Hemorrhoidectomy
MusculoskeletalY N Small Bowel Resection
Y N Back SurgeryY N Splenectomy
Y N Hip ReplacementY N Pancreatectomy
Y N Knee ReplacementY N Ulcer Surgery
Y N Rotator Cuff Repair
Y N Previous History of FractureHead and Neck
Y N Thyroid Surgery
Cardiac/ThoracicY N Parathyroid Surgery
Y N Heart Valve Replacement
Y N Cardiac PacemakerFemale
Y N Cardioverter-DefibrillatorY N Breast Surgery
Y N Heart Stent PlacementY N Hysterectomy
Y N Lung SurgeryY N Tubal Ligation
Y N Cesarean Section
GU
Y N Nephrectomy (Kidney)
Y N Lithotripsy (Kidney Stones)Other
Y N Prostate SurgeryY N Craniotomy
Y N Temporal Artery Biopsy
HerniaY N Cataract Surgery
Y N Inguinal Hernia Repair (Groin)
Y N Umbillical Hernia Repair (Navel)
Y N Femoral Hernia Repair
Y N Incisional Hernia Repair
Y N Ventral Hernia Repair (Abdominal Wall)
REVIEW OF SYSTEMS
Constitutional / YES / NO / Muskuloskeletal Symptoms / YES / NORecent Weight Gain ___ lbs / Leg Pain with Exercise
Recent Weight Loss ___ lbs / Lower Leg Swelling
Fever (as symptom) / Psychiatric
Eyes / Depression
Pain in or around the eyes / Anxiety
Vision Problems / Memory Lapses or Loss
ENMT / Skin/Breast
Hearing loss / Breast Lump
Bleeding Gums / Breast Pain
Cardiovascular / Skin Lesions
Chest Pain or Discomfort / Skin Rash
Fast Heart Rate / Neurologic
Respiratory / Dizziness
Cough / Confusion
Shortness of Breath / Hematologic/Lymph
GI / Easy Bleeding
Black or Bloody Stools / Easy Bruising
Jaundice / Swollen Glands in Neck
Nausea / Groin Lymph Node Swelling
Vomiting / Other
Constipation / Possible Pregnancy
Diarrhea / Sleep Apnea
Abdominal Pain
GERD
GU
Blood in Urine
Urinary Frequency
Pain During Urination
Have you been prescribed a narcotic medication/pain medication from another physician in the last 30 days?
_____Yes _____No
List current Medications
Name of Drug / Dosage (mg, tsp, etc.) / How often do you take this medicineList any known Allergies
Name of Drug / Type of Allergy/IntoleranceNOTICE OF PRIVACY PRACTICES ACKNOWLEDGED
I have been given an opportunity to review, ask questions about and understand Premier Surgical Associates' Notice of Privacy Practices for Protected Health Information (Notice).
Patient or Guardian's Signature ______Date ______
PREMIER SURGICAL ASSOCIATES, PLLC
PLEASE READ
All charges are due at the time of service. If hospitalization or surgery is indicated, we will file your claim directly to your insurance company. Please remember that most insurance companies do not pay the full amount, and therefore, you are responsible for the balance. If there is a problem paying the balance in full, please let us know and we will be happy to work with you.
FINANCIAL RESPONSIBILITY
I understand and commit to the following:
1. I have received a copy of Premier's financial policies and have read and understand these policies.
2. I will pay my co-pay, deductible and co-insurance at the time of service.
3. I will provide the most current insurance information and immediately notify Premier of changes.
4. If surgery is required, all or a portion of my financial responsibility must be paid prior to surgery.
5. I will follow my insurance company's requirements for referrals and pre-authorizations and I understand that if I fail to do so,
my insurance benefits will be reduced and I will be responsible for all denied balances.
6. I understand that I am responsible for all balances after insurance has paid.
7. If I have no insurance, I have informed Premier and I am responsible for 100% of all balances.
8. A collection fee of 30% will be added to all my accounts that are turned over to collection agencies.
Patient's Signature______Date______
INSURANCE AUTHORIZATION AND RELEASE
I request that payment of authorized benefits - including Medicare, and any other government sponsored program, private insurance, and any other health plans - be made to Premier Surgical Associates, PLLC for any services furnished by that provider. I authorize any holder of medical information about me to release to those persons or companies presenting a legitimate request for such information needed to determine these benefits or the benefits payable for related services. I authorize Premier Surgical Associates, PLLC to act as my agent to help me obtain any required pre-certification as well as acting as my agent to help me obtain payment from my insurance companies. I authorize my insurance companies to give Premier Surgical Associates, PLLC any information they require to fulfill this function. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the original.
Patient's Signature ______Date______
Page 4 of 5 08/2010
MEDICAL RECORDS RELEASE
I hereby authorize Premier Surgical Associates, PLLC to release any information in my chart to any medical practitioner, doctor, hospital, medical institution to whom I may be referred to assist with my care. Additionally, I authorize any request for medical information from any medical practitioner, doctor, hospital, medical institution assist in my care.
Patient's Signature ______Date______
FOR MEDICARE SUPPLEMENT POLICIES ONLY
ONE-TIME MEDIGAP ASSIGNMENT AND RELEASE
______
Name Medicare Number
______
Medigap Policy Name Medigap Policy Number ______
I request that payment of the authorized Medigap benefits be made on my behalf to Premier Surgical Associates, PLLC for services furnished to me by them. I authorize any holder of medical information about me to release it to:
______
Name of Policy ______
any information needed to determine these benefits or the benefits payable for related services. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the original.
Patient's Signature ______Date______
Page 5 of 5 08/2010
«PatientFullName» «PatientNumber» «CurrentDate» «CurrentTime»