PATIENT INFORMATION FORM

Transcription

1 PATIENT INFORMATION FORM : Dear Patient, We are currently updating our billing system. As a result, it is very important we received your current patient and insurance information. We appreciate your cooperation and apologize for any inconvenience. Please return completed form to the receptionist. Thank you. PATIENT INFORMATION: First / Last Name: Address: Home Phone:( ) - Cell Phone:( ) - Social Security #: - - Sex: Birth : Address: PRIMARY INSURANCE INFORMATION: Insurance Company: Insured s Name: Group/Policy: ID Number: Insurance Co. Address: Insurance Co. Telephone:( ) Relationship to Insured: (S = Spouse, C = Child, Leave BLANK if Self ) Insured s Birthdate: / / Sex: SSN: - - SECONDARY INSURANCE INFORMATION: Insurance Company: Insured s Name: Group/Policy: ID Number: Insurance Co. Address: Insurance Co. Telephone:( ) Relationship to Insured: (S = Spouse, C = Child, Leave BLANK if Self ) Insured s Birthdate: / / Sex: SSN: - - A/R Responsible: EMPLOYER INFORMATION: Occupation: Work Phone: ( ) - Employer Name: Address: MISCELLANEOUS INFORMATION: Who were you referred by? Pharmacy Name: Pharmacy Phone: ( ) - Marital Status: Employed or Student: If yes, F/T or P/T: EMERGENCY CONTACT: Name: Relationship: Address: Phone: ( ) - SSN:(Optional) - -

2 PLEASE COMPLETE REVERSE SIDE PATIENT AUTHORIZATION FORM PATIENT NAME: PROVIDER: AUTHORIZATION TO RELEASE INFORMATION: I understand that I am financially responsible for all charges not covered by this authorization. I hereby authorize the release of medical information pertaining to medical treatment as requested by my health insurance carrier or the Health Care Financing Administration and its agencies fro determination of benefits coverage. AUTHORIZATION TO PAY INSURANCE BENEFITS: I understand that I am financially responsible for all charges not covered by this authorization. I hereby authorize payment directly to the above named physician or his/her billing organization, otherwise payable to me but not to exceed the regular charges for the services provided. AUTHORIZATION TO RECEIVE MEDICAL ADVICE AND TEST RESULTS VIA I hereby authorize the above named physician or his/her organization to proceed to contact me via . I understand that I am financially responsible for all charges not covered by my insurance company. My balance is expected to be paid in full within 90 days from the date of service. Should this balance not be paid in full by this time, I understand my account will be forwarded to a collection agency along with a collection fee equal to 100% of my balance. MEDICARE Name of Beneficiary Health Insurance Claim Number I request that payment of Medicare benefits be made on my behalf to the physician named above for services rendered to me. I authorize any holder of medical information about me to release to the Health care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand that any procedures or visits that Medicare does not cover as medically necessary will be my financial responsibility. Patient Physician

3 North Shore Medical Associates, p.c. Internal Medicine 107 Northern Blvd., Suite 206 Great Neck, NY www. doctormelgar. com Telephone (516) Michael J. Melgar, MD Fax (516) PRIVACY POLICY ACKNOWLEDGEMENT I acknowledge that I have been given the opportunity to read the privacy policy of North Shore Medical Associates, PC. I understand that I may request a copy for my own records if I wish and that the policy is available online at: Print Name

4 North Shore Medical Associates, p.c. Internal Medicine 107 Northern Blvd., Suite 206 Great Neck, NY www. doctormelgar. com Telephone (516) Michael J. Melgar, MD Fax (516) Medicare Annual Waiver Dr. Melgar has advised me that the procedure(s) today, listed below, may not be fully reimbursed by Medicare as they may not be considered medically necessary by Medicare. Although Medicare may reduce/deny the procedure(s), I have advised the doctor to proceed with the services and will assume full responsibility for the payment. I am aware that Medicare does not pay for well visits and most screening tests. CPT DESCRIPTION CHARGE PT INITIALS Comprehensive Office Visit Medicare Allowed Amount EKG (Electrocardiogram) Medicare Allowed Amount Venipuncture Medicare Allowed Amount Urinalysis Medicare Allowed Amount Stool Guiaic Medicare Allowed Amount MCCARDS Take Home Stool Card Kit $ PATIENT NAME: DATE:

5 Please read and complete the items below All patients please answer these questions. Yes No I would like to have testing for sexually transmitted diseases during this visit Yes No I would like to review techniques for smoking cessation during this visit For Men 50 to 75 years old: I have read the attached PSA information sheet and have decided to either have or not have the PSA test done as directed below. I understand the risks and benefits of this test and have been given adequate opportunity to have my questions answered. I have decided to have the PSA blood test I have decided NOT to have the PSA blood test First Name: Last Name: : :

6 North Shore Medical Associates PSA Prostate Screening Should you have the test? Although the debate surrounding the PSA test may seem new, the test has been surrounded by controversy since it first became available in Most recently the PSA has been in the news because the United States Preventative Services Task Force (USPSTF) has recommended that the PSA no longer be a routine part of mens physical exams. This has lead to a good deal of confusion for patients. What is the PSA? PSA (Prostate Specific Antigen) is a blood test. PSA is a protein produced in normal prostate tissue. Researchers noticed that some prostate cancer cells made higher levels of PSA than most normal prostate cells and concluded that this might be an easy noninvasive way to screen for prostate cancer. Since that time it has been a common part of the blood work done during physical exams for most men between the ages of 40 and 75. Why is there controversy about the test? The problem with the test is that sometimes normal prostate tissue can produce high levels of PSA and cancerous prostate tissue can produce normal levels of PSA. These issues can cause both false positive and false negative results. Studies have been done looking at whether the PSA test results in reduced death rates or longer lives for prostate cancer patients. NEWSLETTER These studies seem to indicate there is no benefit. This may not seem to make sense but the truth is that early detection does not always result in better outcomes. Many prostate cancers are relatively harmless and may never have resulted in death. Other may be so aggressive that even in its earliest stages treatment has little benefit. There may be some types where treatment will help but there is no way currently to separate the various types. Is there a down side to doing the test? A positive PSA often results in the need for a painful biopsy. If the biopsy is positive then radiation or surgery is often recommended. These treatments all have potential side effects. Impotence is a very common complication, but obviously there can be a good deal of discomfort and in rare cases even more serious complications are possible. So what should patients do? Its important to weigh the risks of doing the test (unnecessary treatments) against the benefits, which are debatable at this point, in order to make a decision. The USPSTF is saying that PSA s should not be done routinely on men as part of their physical exam. The patient should discuss this with their physician and request the test only once they fully understand the pros and cons