TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A.

Transcription

1 TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A. James T. Siminski, M.D., FCCP Donald L. Washington Jr, M.D Hospital Parkway, Suite 403 Bedford, TX (817) (817) Fax Thank you for choosing Texas Pulmonary & Critical Care Consultants. Your appointment is scheduled with on at. Please arrive 30 minutes early to complete any necessary forms, testing, etc. Enclosed you will find your new patient paperwork. Please be sure to put your name and date of birth on each page. Please use black ink. All paperwork MUST be in our office 5 days BEFORE the visit. If we do not have your paperwork, you may be asked to reschedule your appointment. We are sorry to be so rigid about this, but the structure of the electronic medical record makes this necessary. Feel free to fax your paperwork to our office at (817) IT IS IMPORTANT THAT YOU BRING YOUR INSURANCE CARD AND YOUR DRIVER S LICENSE SO WE CAN SCAN A COPY. It is YOUR responsibility to make sure that your prior medical records and chest x-rays/ CT scans (actual films or CD ROM, not just the reports) are in our office at the time of your visit. Please thoroughly complete the section in the patient health questionnaire listing your medications or bring all of the medication bottles (including any supplements) and inhalers you take regularly. Please sign and initial all areas that have an asterisk on the form for Authorization for Use or Release of Information. We look forward to meeting you at your first office visit. If we can assist you with questions prior to your visit, please feel free to call. You may also see our website at for answers to questions you may have.

2 TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A Hospital Parkway, Suite 403 Bedford, TX (817) DIRECTIONS: Major crossroads are 183 (Airport Freeway), Central Dr. and Murphy Drive. We are south of 183, and east of Central Drive and West of Murphy Drive. You can get to the office from either Central or Murphy. We are located in the Professional Building of Harris Methodist Hospital next to the Emergency Room Entrance on the back side of the hospital. You'll need to go into the main entrance of the Professional Building, walk to the elevators. Once on the elevator you'll proceed to the fourth floor and then exit to the right. We are the second door on the left.

3 PATIENT HEALTH QUESTIONNAIRE Texas Pulmonary & Critical Care Consultants, PA Patient Name: DOB: Age: Height: Names of physicians now treating you: Please list any surgeries you have had: Please list ALL medical illnesses: ALLERGIES: Please list all medications to which you are allergic and what the reaction was. Medication Reaction Medication Reaction Medication Reaction Medication Reaction Are you allergic to iodine, shrimp or shellfish? Yes No Have you had a problem with dye for x-rays? Yes No Reaction: Please list all medications you are taking, including inhalers, vitamins and non-prescription medications:

4 Name: DOB: Page 2 of 4 Have you ever smoked? Yes No If yes, at what age did you start? Do you still smoke? Yes No If you quit, at what age did you quit? Cigarettes: Yes No How many packs per day? Cigars: Yes No Pipe: Yes No

5 Name: DOB: Page 3 of 4 Do you use alcohol? Yes No, but used to Never If yes: Daily Weekly Monthly Have you used other substances? Yes No If yes, what? Do you exercise regularly? Yes No If yes, specify: Check any of the diseases that run in your family AND please note who had it: COPD Asthma Eczema Hay fever Nasal polyps Lung disease Lung cancer Cancer (list type) Breast cancer Colon cancer Skin melanoma Pancreatic cancer Heart disease Coronary artery disease High blood pressure Stroke High cholesterol Diabetes Dementia/Alzheimer s Blood clot to lungs Blood clot to leg veins Mother Father Sister Brother Other (explain)

6 Name: DOB: Page 4 of 4 List all occupations that you have had: Have you been exposed to chemicals or industrial dusts? Yes No If so, what? Do you have pets at home? Yes No If so, what kind? Do you have any hobbies that expose you to chemicals, fumes or animals? Yes No If so, what kind?

7 TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A. Advanced Practice Provider Consent This facility has on staff advanced practice providers to assist in the delivery of pulmonary care. These advanced practice providers are not physicians. They have received advanced education and training in the provision of health care. Each can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. I have read the above and hereby consent to the services of an advanced practice provider for my health care needs. I understand that at any time I can refuse to see the advanced practice provider and request to see a physician. Name Date Signature

8 PATIENT REGISTRATION FORM Date: Patient Name Birth Date Sex SSN Last First Middle Are you currently residing in a skilled nursing facility? Yes No If yes, name of facility Home Address Street City State Zip+4 Home Phone Cell Phone Work Phone Preferred contact method for reminders (select one or more): Text (cell phone above) Voice message (circle preferred number above) (below) Do Not Contact address Patient Employer Employer Address Employer Phone I decline access to the portal Street City State Zip+4 Marital Status Religious Preference Patient Language Ethnicity Latino/Hispanic Other Decline to Answer Race American Indian or Alaskan Native Asian Asian Pacific American Black/African American Caucasian (White) Hispanic More Than One Race Native American Native Hawaiian Other Race Pacific Islander Subcontinent Asian American Unknown Decline to Answer Spouse s Name Spouse s Employer Spouse s Work Phone Address Referred By Phone Fax Address Street City State Zip+4 Primary Care Physician Phone Fax Address Street City State Zip+4 List other physicians you are currently seeing Notify in case of emergency (Do not list anyone who lives with you) Name Phone Relationship Address Street City State Zip+4 Have you signed a: Living Will: Yes No DNR (Do Not Resuscitate): Yes No (Please provide a copy) Durable Power of Attorney: Yes No Date signed: (Please provide a copy) Pharmacy Phone Are you currently using a DME (Durable Medical Equipment) Company? Yes If yes, which one? If no, who does your insurance company require you to use? Who does your insurance company require you to use for: Lab X-ray Is this a work-related illness/injury? Yes No Date of illness/injury Date last worked Cause of accident, if any I hereby authorize release of my medical records from to Texas Pulmonary & Critical Care Consultants, PA. No Signature of Patient or Responsible Party Date

9 FINANCIAL POLICY PRIMARY INSURANCE POLICY: Insurance Co. ID No. Group No. Name of Insured Insured s DOB Ins Start Date Relationship to Patient SSN Sex Claims Mailing Address Co-pay Phone No. SECONDARY INSURANCE POLICY: Insurance Co. ID No. Group No. Name of Insured Insured s DOB Ins Start Date Relationship to Patient SSN Sex Claims Mailing Address Co-pay Phone No. Responsible Party Name Phone Relationship Address Street City State Zip+4 Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you read and sign prior to any treatment. All patients must complete our Information and Insurance Form before seeing the doctor. Full payment or copayment (if applicable) is due at the time of service. We accept cash, check, Visa, MasterCard, Discover or American Express. Regarding Insurance We cannot bill your insurance company unless you give us your insurance information. If we are nonparticipating with your insurance, and they have not paid the balance within 90 days, the balance will be transferred to you. Please be aware that some, and perhaps all, of the services provided may be non-covered services and/or not considered reasonable and necessary under the Medicare Program and/or other medical insurance. These charges will be your responsibility. Our office makes every effort to obtain referral authorizations from the Primary Care offices for patients on HMOs. Should we not be able to obtain a referral, charges will be your responsibility. Out of Network Billing The physicians may not be participating physicians with your insurance plan, and if not, benefits may be reduced as such. You will be responsible for any unpaid charges and/or balances. Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company s (excluding Medicare) arbitrary determination of usual and customary rates. Missed Appointments Unless canceled at least 24 hours in advance, our policy is to charge for missed office and oximetry appointments at the rate of $25.00 and a separate charge for sleep testing at the rate of $ Please help us serve you better by keeping scheduled appointments. Signature of Patient or Responsible Party Date Research Consent I give permission for clinical and physiologic data from my medical records to be used for educational and research purposes. I understand that my identity and contact information (name, SS#, birth date, address, etc.) will never be attached to or processed with such data. Signature of Patient or Responsible Party Date

10 Appointment of Authorized Representative Identifying Information Patient s name Member s name Member s address Member s plan identification # Provider s plan identification # Service not paid / not authorized by plan Date(s) of service Appointment. I,, appoint Texas Pulmonary & Critical Care Consultants, P.A. and/or Sleep Consultants, Inc. to act as my authorized representative in requesting an appeal from in the event of denial of services/denial of payment. Directed payment. I agree that if the payment denial is overturned on appeal, the plan s payment should be paid directly to my authorized representative, and direct the plan to do so in that event. Member s signature Date

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12 Texas Pulmonary & Critical Care Consultants, P.A. Sleep Consultants, Inc. Acknowledgment of Review of Notice of Privacy Practices I have reviewed this office s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document. Signature of Patient or Personal Representative Date Name of Patient or Personal Representative Description of Personal Representative s Authority

13 Texas Pulmonary & Critical Care Consultants, PA Consent to release Protected Health Information (PHI) I understand that in order to disclose my PHI, Texas Pulmonary & Critical Care Consultants, PA, must have my consent, therefore I authorize Texas Pulmonary & Critical Care Consultants, PA to disclose my PHI as described in the provided forms to the recipients listed below: Description of the information to be disclosed (check all that apply) All Procedures Test Results Appointments Other Surgeries Billing/Account information Name(s) of the person(s) authorized to obtain the above-mentioned information. (e.g. physician other than your referring doctor, family members and other specified person/persons) Name: Relationship: Name: Relationship: Contact Information: I authorize Texas Pulmonary & Critical Care Consultants, PA to contact me at the following number with results or questions: Home Cell Work May we leave a detailed message on your answering machine or voic ? Yes No Failure to check one of these boxes may delay results By Patient: (print and sign) Date: Or Patient s Representative (print name, sign and describe authority) Date: Authorization expires one year from signature date. In signing this HIPAA Patient Acknowledgement form, you acknowledge and authorize, that you hold harmless this Healthcare Facility, its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring from this authorization. I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law; that this authorization remains effective until this Healthcare Facility is in actual receipt of a signed revocation or until the records retention period required under federal and state law has expired and the records have been destroyed; that I have the right to revoke this authorization at any time, provided I do so in writing; that I have been given the opportunity to ask questions; that I have received a copy of the signed authorization; that I may inspect a copy of my PHI to be used or disclosed under this authorization; that this Healthcare Facility has not conditioned provision of services to or treatment of me upon receipt of this signed authorization; and that I may refuse to sign this authorization. A copy of this signed, dated Authorization shall be as effective as the original. A copy of our Notice of Privacy Practices will be provided at your request.