INSTRUCTIONS. Once you complete the forms, save the file to your desktop for your records, then attach in an to:

Transcription

1 INSTRUCTIONS For your convenience you can fill out the following forms on your computer if you have Adobe Acrobat Reader installed. Fields are highlighted in blue. Use the tab key to move from field to field. Once you complete the forms, save the file to your desktop for your records, then attach in an to: Please save the file with your name. For example : JohnSmith.pdf. You can add your signature to the forms at the office. If you have any problems or questions, please call the office at for assistance.

2 PATIENT INFORMATION: (Please use full legal name, no nicknames) Today s : *Last Name: *First Name: Middle Initial: *Address: *City *State: *Zip: *Home Phone: *Cell Phone: * Address: Send appointment reminders sent to your ? Y N Social Security# * of Birth *Age *Sex M F Marital Status: Married Widowed Single Minor Separated Divorced Partnered *Employer/School Name: Occupation: *Address: Work Phone#: *City *State: *Zip: Primary Care Physician: Phone #: Emergency Contact Name: Relation: Phone#: Who may we thank for referring you? GUARANTOR INFORMATION: (List insured name responsible for bill use full legal name, no nicknames *Relationship of Guarantor to Patient: Self Spouse Parent Other *Last Name: *First Name: Middle Initial: *Address: *City *State: *Zip: *Home Phone: *Cell Phone: *Social Security# * of Birth *Age *Sex M F *Employer Name: Work Phone#: *Employer Address: *City *State: *Zip: INSURANCE INFORMATION: IF SOMEONE OTHER THAN PATIENT IS THE INSURED PARTY, PLEASE INCLUDE DATE OF BIRTH FOR CLAIMS PRIMARY INSURANCE: *Insurance Company: *Insured s Name: *Insured s of Birth: *Policy / ID#: *Group#: SECONDARY INSURANCE: *Insurance Company: *Insured s Name: _ *Insured s of Birth: *Policy / ID#: *Group#: *REQUIRED FIELDS PLEASE COMPLETE FOR BILLING. ASSIGNMENT AND RELEASE I certify that I, and / or my dependent(s), have insurance with and assign directly to Dr. Michael F. Pratt and / or Insurance Company Progressive Audiology Center, Inc. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. I understand any expenses incurred in collecting any monies due on this account are the responsibility of the patient. The above-named physician may use my healthcare information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is complete. : Signature of Patient, Parent, Guardian or Personal Representative : Please Print Name of Patient, Parent, Guardian or Personal Representative

3 Patient Name: Today s : Age of Birth of last physical examination What is the reason for your visit? SYMPTOMS Check R symptoms you currently have or have had in the past year. GENERAL *Chills *Depression *Dizziness *Fainting *Fever *Forgetfulness *Headache *Loss of Sleep *Loss of Weight *Nervousness *Numbness *Sweats MUSCLE/JOINT/BONE Pain, weakness, numbness in: *Arms *Hips *Back *Legs *Feet *Neck *Hands *Shoulders GENITO-URINARY *Blood in Urine *Frequent Urination *Lack of Bladder Control *Painful Urination GASTROINTESTINAL *Appetite Poor *Bloating *Bowel Changes *Constipation *Diarrhea *Excessive Hunger *Excessive Thirst *Gas *Hemorrhoids *Indigestion *Nausea *Rectal Bleeding *Stomach Pain *Vomiting *Vomiting Blood CARDIOVASCULAR *Chest Pain *High Blood Pressure *Irregular Heart Beat *Low Blood Pressure *Poor Circulation *Rapid Heart Beat *Swelling of Ankles *Varicose Veins EYE, EAR, NOSE, THROAT *Bleeding Gums *Blurred Vision *Crossed Eyes *Difficulty Swallowing *Double Vision *Earache *Ear Discharge *Hay Fever *Hoarseness *Loss of Hearing *Nosebleeds *Persistent Cough *Ringing in Ears *Sinus Problems *Vision - Flashes *Vision - Halos SKIN *Bruise Easily *Hives *Itching *Change in Moles *Rash *Scars *Sore that Won t Heal Are you pregnant? Number of Children Conditions Check R conditions you currently have or have had in the past year. *AIDS *Alcoholism *Anemia *Anorexia *Appendicitis *Arthritis *Asthma *Bleeding Disorder *Breast Lump *Bronchitis *Bulimia *Cancer *Cataracts *Chemical Dependency *Chicken Pox *Diabetes *Emphysema *Epilepsy *Glaucoma *Goiter *Gonorrhea *Gout *Heart Disease *Hepatitis *Hernia *Herpes *High Cholesterol *HIV Positive *Kidney Disease *Liver Disease *Measles *Migraine Headaches *Miscarriage *Mononucleosis *Multiple Sclerosis *Mumps *Pacemaker *Pneumonia *Polio *Prostate Problem *Psychiatric Care *Rheumatic Fever *Scarlet Fever *Stroke *Suicide Attempt *Thyroid Problems *Tonsillittis *Tuberculosis *Typhoid Fever *Ulcers *Vaginal Infections *Venereal Disease Medication List medications you are currently taking Pharmacy Name Phone SYMPTOMS Check R symptoms you currently have or have had in the past year. Allergies

4 Relation Age State of Health Father Mother Brothers Sisters Age at Death Cause of Death Check R if your blood relatives had any of the following: Disease Relationship to You Arthritis, Gout Asthma, Hay Fever Cancer Chemical Dependency Diabetes Heart Disease, Strokes High Blood Pressure Kidney Disease Tuberculosis Other Hospitalization Year Hospital Reason for Hospitalization and Outcome Pregnancies Year of Birth Sex of Birth Complications, if any Health Habits Check R which you use and how much you use. Caffeine Tobacco Have you ever had a blood transfusion? *Yes *No Street Drugs Conditions If yes, please give approximate Check dates R conditions you currently have or have had in the past Other year. Serious Illness/Injuries Outcome Occupational Check R if your work exposes you to: Stress Hazardous Substances Heavy Lifting Other Occupation: To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibiity to inform my doctor if I, or my minor child, ever have a change in health. Signature of Patient, Parent, Guardian or Personal Representative Please Print Name of Patient, Parent, Guardian or Personal Representative Reviewed By SYMPTOMS

5 NEW PATIENT INFORMATION: The physician and staff of Woodstock Ear, Nose & Throat are pleased you have selected us to privide your ENT care. Please READ THIS LETTER IN ITS ENTIRETY and sign at the bottom. 1. We encourage our patients to know their insurance plans and the restrictions your plan may have. Please call your member services number on your insurance card if you have any questions regarding coverage for your visit. Due to the MANY different insurance plans it is IMPOSSIBLE for our staff to know all the details of all insurance companies. Ultimately this is a contract between you, the patient, and your insurance company. As a courtesy we will file your insurance, but you will be responsible for any balance not covered by your insurance company. 2. If your Insurance Company requires a referral to see a Specialist, it is your responsibility to obtain the referral from your Primary Care Physician prior to your appointment. If our office does not have a referral from your PCP s office at the time of your visit, WE WILL RESCHEDULE YOUR APPOINTMENT. 3. Please be prepared to pay your specialist co-payment when you check-in for your office visit. We accept VISA, MasterCard, cash and checks (we process checks electronically). 4. We require 24 hours prior notice for an appointment cancellation. If your appointment is not cancelled 24 hours prior to the appointment time you will be charged a $25.00 NO SHOW FEE. This fee is billed directly to you. Insurance Company is not responsible for any portion of this charge. 5. We understand that your time is important and our office maintains high standards of staying on time for appointments. We ask that you arrive a few minutes prior to your scheduled appointment time so that you can check-in and update any information that may be needed. If you are 15 minutes or more late for your appointment, your visit will be rescheduled so that we can stay on time for our other patients. 6. It is your responsibility to keep the office informed of any changes in personal information or insurance information. Please inform front desk of any changes when you check in for your appointments. 7. Our office DOES NOT fax prescriptions. We send prescriptions electronically to local pharmacies or provide you with a paper prescription if you use mail order pharmacies. If you use mail order pharmacies you must MAIL the ORIGINAL prescription to the pharmacy. Mail order pharmacies WILL NOT accept faxed prescriptions from patients. I, have read and understand the office policies for Woodstock Print Name Ear, Nose and Throat and understand my responsibilities as a patient. Patient Signature (or Guardian Signature) Print Patient s Name (only if patient is a minor)

6 NEW GUIDELINES FOR MEDICAL INFO NEEDED: In order to comply with the MEANINGFUL USE MEASURE (f), which requires patients to have access to their Personal Health Record, we must obtain the following information. Name: of Birth: RACE: *Asian *Hawaiian *Pacific Islander *Black/African American *White *Hispanic *Other *Refuse to Report ETHNICITY: *Hispanic or Latino *Non Hispanic or Latino *Refuse to Report PRIMARY LANGUAGE SPOKEN: *English *Indian (Includes Hindi and Tamil) *Russian *Spanish *Other: *I do not wish to answer the above questions. Signature

7 APPOINTMENT POLICY UPDATE EFFECTIVE: 5/1/2013 We require 24 hours prior notice to cancel OR reschedule an appointment with Dr. Pratt. We require 48 hours prior notice to cancel OR reschedule a hearing test. If your appointment is not cancelled 24 or 48 hours prior to the appointment time you will be charged a $25.00 No- Show Fee FOR EACH APPOINTMENT. If you are 15 minutes or more late for your appointment this will be considered a missed appointment and a fee will be charged/ This is billed directly to you. NO INSURANCE COMPANY will pay any portion of this fee. I have read and understand the updated cancellation policy for Woodstock Ear, Nose and Throat Patient Signature (or Guardian Signature) Print Patient Name

8 MICHAEL F. PRATT, M.D., P.C. D/B/A WOODSTOCK EAR, NOSE AND THROAT RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM I hereby acknowledge that I have been presented with a copy of Woodstock Ear, Nose and Throat Notice of Privacy Practices Signature Name of Patient

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