Patient Information Form

. PULMONOLOGY AND SLEEP SERVICES OF SAN ANTONIO, LLC

PATIENT INFORMATION FORM

11901 Toepperwein Rd Suite #1401

Live Oak, TX (210) 599-1433

Demographics (Complete in full) : Today’s Date ______

Name ______Age______Date of Birth______

Address______HM Ph # ______

City ______State______Zip ______Cell Ph# ______

SSN ______Single_ Separated_ Married_ Divorced_ Wk. Ph. # ______

Race: ______Ethnicity ______Gender ______

Preferred Communication: ______Primary Language: ______

E-mail address: ______(necessary for appt confirmation)

Employment Information:

Employer’s Name______Occupation______

Address: ______City______State: ____ Zip______

Employer’s Telephone ( ) ______Ext: ______

Emergency Contact Information:

Name______Telephone ( ) ______Relation______

PREFERRED PHARMACY: ______Telephone ( ) ______

Primary Care Provider: ______Referring Provider: ______

Reason for consultation: ______

Insurance Information:

Primary Insurance Name ______Insured SS#: ______

Name of Insured ______Insured’s Date of Birth ______

Employer’s Name______Employer’s Telephone ( ) ______

Secondary Insurance Name______Insured SS#: ______

Name of Insured ______Insured’s Date of Birth ______

Employer’s Name ______Employer’s Telephone ( ) ______

Signature below is only acknowledgment that you have received the Notice of our Privacy Practices

Patient Name: ______Signature: ______Date: ______

Assignment of Benefits

I, the undersigned, understand that I am financially responsible for all charges if not covered by insurance.

I hereby authorize the release of all information necessary to secure payment.

I hereby assign all Medical/surgical benefits to Nasir Syed, MD/Muhammad Talib, MD

I further understand a 35% fee will be added to my account in the event it is necessary for my account to be forwarded to a Collection Agency. I authorize the release of any medical information needed to determine these benefits.

Signature Date

Medication List

Patient Name: ______DOB: ______

Medication / Dosage / Directions / D/C DATE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Drug Allergies:

______

Reviewed Date: Initials:

1.______

2.______

3.______

History and Physical

Name: ______Date: ______

SS#______DOB: ______Occupation: ______

Address: ______

Home Phone: ______Work Phone: ______

Work Address: ______

Emergency Contact: ______

Phone Number: ______Relation: ______

Reason for visit: ______

Medical History

[ ] Abdominal Pain [ ] Circulation problems [ ] Kidney Stones [ ] Thyroid Problems

[ ] Allergies/Hay Fever [ ] Chronic Bronchitis [ ] Liver Problems [ ] Tuberculosis

[ ] Anemia/Bruise Easily [ ] Depression / Anxiety [ ] Osteoporosis [ ] Ulcer / Gastritis

[ ] Arthritis: [ ] Diabetes [ ] Pericarditis [ ] Ulcerative colitis

Type: ______[ ] Emphysema [ ] Pleurisy [ ] Other:

Yr. Diagnosis: ______[ ] Gout [ ] Psoriasis ______

[ ] Asthma [ ] Heart Problems [ ] Rheumatic Fever ______

[ ] Back pain / Recurrent [ ] Headaches [ ] Sinus Problems

[ ] Blood clots in legs/lungs [ ] High Cholesterol [ ] Stool – Bloody/Tarry

[ ] Cancer: ______[ ] HIV / AIDS [ ] Seizures

[ ] Chest Pain [ ] High Blood Pressure [ ] Stroke

Surgeries:

______

Family History:

Father Mother Grandparent Sibling Children

Alive/Living [ ] [ ] [ ]

Arthritis [ ] [ ] [ ] [ ] [ ]

Asthma [ ] [ ] [ ] [ ] [ ]

Cancer [ ] [ ] [ ] [ ] [ ]

Diabetes [ ] [ ] [ ] [ ] [ ]

Heart Disease [ ] [ ] [ ] [ ] [ ]

High Blood Pressure [ ] [ ] [ ] [ ] [ ]

Kidney Disease [ ] [ ] [ ] [ ] [ ]

Mental Illness [ ] [ ] [ ] [ ] [ ]

Migraines [ ] [ ] [ ] [ ] [ ]

Osteoporosis [ ] [ ] [ ] [ ] [ ]

Stroke [ ] [ ] [ ] [ ] [ ]

Seizures [ ] [ ] [ ] [ ] [ ]

Thyroid Disease [ ] [ ] [ ] [ ] [ ]

Other [ ] [ ] [ ] [ ] [ ]

Name: / DOB: / Date:

Circle YES or NO if any of the following are affecting you significantly.

CONSTITUTIONAL / Gastrointestinal / PSYCHIATRIC / SLEEP
Y / N / Recent Weight Gain / Y / N / Stomach Pain / Y / N / Excessive Worries
Y / N / Recent Weight Loss / Y / N / Diarrhea / Y / N / Anxiety
Y / N / Fatigue / Y / N / Constipation / Y / N / Easily losing temper
Y / N / Fever / Y / N / Heartburn / Y / N / Depression
EYES / Genitourinary / Y / N / Agitation
Y / N / Loss of vision / Y / N / Difficulty urinating / Y / N / Excessive daytime sleepiness
Y / N / Double/blurred vision / Y / N / Pain or burning w/urination / Y / N / Snoring
Y / N / Dryness / Y / N / Getting up at night to urinate / Y / N / Difficulty falling asleep
Y / N / Feels like something in eye / Y / N / Sexual Difficulties / Y / N / Difficulty staying asleep
Ears-Nose-Mouth-Throat / Y / N / Prostate troubles / Y / N / Non-restful Sleep
Y / N / Loss of hearing / MUSCULOSKELETAL / ENDOCRINE
Y / N / Nosebleeds / Y / N / Joint Pain / Y / N / Excessive Thirst
Y / N / Dryness in mouth / Y / N / Joint Swelling / HEMATOLOGIC/LYMPHATIC
Y / N / Runny Nose / Y / N / Muscle Weakness / Y / N / Swollen glands
Y / N / Bleeding Gums / SKIN / Y / N / Bleeding easily
Y / N / Frequent sore throat / Y / N / Easily bruising / ALLERGIC/IMMUNOLOGIC
Y / N / Hoarseness / Y / N / Redness / Y / N / Frequent Sneezing
Y / N / Difficult swallowing / Y / N / Rash/Ulcers / Y / N / Frequent Infections
Cardiovascular / NODULES / BUMPS / EQUIPMENT
Y / N / Pain in Chest / Y / N / Hair Loss / Y / N / Home Oxygen
Y / N / Irregular heart beat / Y / N / Color changes hands/feet / Liters:
Y / N / Swollen legs or feet / NEUROLOGICAL / Y / N / At night
Respiratory / Y / N / Headaches / Y / N / Walking
Y / N / Shortness of breath / Y / N / Dizziness / Y / N / All the time
Y / N / Cough / Y / N / Fainting / Y / N / CPAP Setting:
Y / N / Coughing blood / Y / N / Loss of consciousness / Y / N / BIPAP Setting:
Y / N / Wheezing / Y / N / Memory Loss / Y / N / Nebulizer

Have you been exposed to ASBESTOS? ______

Do you have Birds at home? ______

Habits

Smoke Status: [ ] Current Smoker [ ] Former Smoker Year Quit: ______[ ] Never Smoked Packs Daily: ______[ ] Alcohol Type: ______

How Long: ______Amount: ______

Interested In Stopping: [ ] Yes [ ] No [ ] Drugs: [ ] Yes [ ] No

Authorization for Release of Medical Information

Patient Name: ______Date of Birth: ______

Address: ______City/State/Zip: ______

I hereby authorize: ______

I understand that my medical record may contain copies of information for the results of HIV Antibody Testing (Aids) or treatment for communicable diseases, treatment for mental health problems, testing or treatment of drug or alcohol abuse.

I further authorize the release of such confidential information to the indicated party. I authorize the fax transmission of the records.

Records are to be released to:

PULMONOLOGY AND SLEEP SERVICES OF SAN ANTONIO, LLC

11901 Toepperwein Rd Suite #1401 Live Oak, TX 78233

Nasir S. Syed M.D.

Muhammad Talib M.D.

Live Oak, TX 78233

Tel: (210) 599-1433

Fax: (210) 599-1803

I hereby request the following information to be released:

Entire Medical Records______Progress Notes ______

X-Rays or EKG Reports ______Surgery Notes______

Other ______

Records are to be released for the purposes of:

Further Medical Care ______Other______

Insurance Payment ______

Patient Signature: ______Date: ______

Our Financial and Office Policies

Thank you for choosing PULMONOLOGY & SLEEP SERVICE OF SAN ANTONIO, LLC as your healthcare provider. We are committed

to providing our patients, with the best available medical care. Our billing department will be available to discuss our fees and policies with you if you have any questions. We ask that all responsible parties read and sign our financial and office policies

and complete the patient information form prior to seeing the physician. As you read, please initial beside each topic to indicate your understanding of our policies. Please remember that your insurance is a contract between you (or your employer) and the insurance company.

___ 1. All co-pays, deductibles, and/or co-insurance are due at the time of service. We do not choose these fees. They are provided

To our office by your insurance company when we call to verify benefits and /or the terms agreed upon by you

(or your employer) and your insurance company.

___ 2. We verify insurance benefits as a courtesy to our patients. All charges are your responsibility whether your insurance

company pays or does not pay. Not all services are a covered benefit by your medical plan. Please contact your

Insurance company if you have any questions regarding your health care coverage prior to receiving services. You

are ultimately responsible for all charges, that are not covered under your health care policy.

___3. We will collect all co-payments, deductibles or charges for non-covered services at the time upon check in. If you have a

Balance on your account we will ask for that payment as well. For your convenience, we accept Cash, Check, Visa

and MasterCard.

___4. Some insurance companies require a referral from your primary care physician before being seen by a physician. If your

Appointment requires a referral from your primary care physician, that referral will need to be on file with our office before

the appointment day, Please contact your primary care physician to ensure this referral is sent to our office in time for the

upcoming appointment. If you are seen without a referral on file and the insurance company does not pay, you will be

responsible for all charges.

___ 5. Please ensure that all personal and insurance information is correct at the time of each visit. We will only bill the insurance

company on file. It is not uncommon for someone to change their phone number or address and forget to inform us. This

leads to fragmented communication. Please inform the receptionist if your address, phone number, or insurance

information has changed (or if you anticipate that it will be changing in the near future).

___ 8. We allow 90 days for payment of any balances that are the responsibility of the patient. If we do not receive full payment in

90 days, the account will be referred to collections. We understand that temporary financial problems may affect timely

payments of your balance. We encourage you to communicate any such problems to us, so that we may assist you

to keep your account in good standing.

___9. In the event your account is sent to collections (Commercial and Medical Credit Services) there will be additional fees assessed by the collection agency.

___10. (A) Appointments not cancelled with a 24 hours notice and any “no show” appointments will be subject to a charge

of $ 25.00. Please note that this fee is not covered by your insurance company.

(B) Any diagnostic (Pulmonary Function Test) not cancelled with a 24 hour notice, will be subject to a charge of $50.00.

___11. Any personal check returned for insufficient funds, will be charged $35.00 in addition to the amount to the amount

of the check. After one instance of a returned check, all further payments will be required to be in the form of credit

card, cash or money order only.

___12. There is $25.00 fee for the first 20 pages and $0.25 per copies of medical records not requested by another physician.

The patient must complete an authorization to disclose health information and the fee will be collected before

the records will be released.

___ 13. As of May 01, 2015 all prescription refills must be requested thru our Portal at http://sevocity.com/patientportal. Generic

Password: (sleep01). Only if the patient does not have access to a computer the patient may request the medication

refill (s) with your pharmacy (please allow 72 hour when requesting refill(s) with your pharmacy).

I HAVE READ AND UNDERSTAND THE ABOVE POLICIES

______/______/______

Signature of patient (or responsible party) Date

______

Print Name of the Patient (or responsible party) Witness

Patient Information Form

Insurance Information:

Assignment of Benefits

Signature ______Date ______

Signature Date