Phone: (512) Fax: (512)

Transcription

1 Phone: (512) Fax: (512) NEW PATIENT INFORMATION Patient Name DOB Age SSN Today s Date Gender Single Married Widowed Divorced Address/City/State/Zip Cell phone Occupation (if minor, guardians occupation) Home phone Employer Name Work phone Employer Address City, State, Zip Name of Spouse or Parent Home phone Address Work phone City, State, Zip Occupation Employer Name of the Insured Party DOB Referring Physician/Primary Care Physician Phone Fax Address/City/State/Zip **How did you hear about us? FINANCIAL POLICIES **Payment is due at the time services are rendered. **We will see that you get the best medical care and will make every reasonable effort to aid you in obtaining the maximum benefits allowed with your insurance coverage. ASSIGNMENT AND RELEASE I authorize my insurance benefits to be paid to the physician. I understand that I am responsible for any deductibles, co-insurance, and non-covered services. I also authorize my physician to release any information required to process insurance claims. Signature Date Page1

2 REVIEW OF SYMPTOMS Please circle any of the following symptoms that you are currently experiencing or that you have had recently: Constitutional: Eye, Ear, Nose or Throat: Lungs: Fever, weight loss, weight gain, night sweats, severe itching, loss of appetite, Fatigue, cold intolerance and or heat intolerance Dry eyes, itchy eyes, vision changes, cataracts, glaucoma, light avoidance, eye pain, eye discharge, itchy ears, ear infections, ringing in ears, loss of balance, loss of hearing, deviated septum, nose bleeds, post nasal drip, nasal congestion, sore throat, hoarseness, difficulty swallowing, recurrent throat infections, loss of smell and or taste, dry mouth, dental cavities. Shortness of breath, cough, nighttime coughing, coughing up blood, wheezing, Chest congestion, chest tightness, hard to catch your breath Lymph Nodes: Heart: Intestinal tract: Reproductive: Urinary: Swelling, tenderness. Chest pain, palpitations, swelling of ankles, inability to lie flat in bed. Nausea, vomiting, heartburn, indigestion, trouble swallowing liquids or fluids, abdominal pain, constipation, diarrhea, excessive gas, food intolerance, acid or sour taste in mouth, blood in stool, jaundice. Irregular or skipped periods, unusual vaginal bleeding, menopause, Infertility, miscarriages, impotence, unplanned pregnancy, planned pregnancy. Kidney stones, inability to urinate, prostate problems, kidney infections. Rheumatologic & Orthopedic: Early morning stiffness, joint swelling, joint pain, gout, low back pain, Osteoporosis, fractured bones. Skin: Neurologic: Skin rash, hives, eczema, skin tumors or growth, excessive hair loss. Fainting spells, severe headaches, epilepsy (seizers), difficulty with memory Inability to concentrate Page2

3 Provide explanation on any symptoms that are particularly bothersome to you: Patient Name: Today s Date TB Screening Questionnaire Patient Name: Date of Birth: Date of Visit: In the last year, have you experienced any of the following symptoms for more than three weeks at a time? SIGN & SYMPTOM REVIEW: YES NO Persistent cough Excessive sweating at night Unexplained weight loss Coughing up blood Excessive fatigue Persistent fever History Questionnaire Page3

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9 Acknowledgment and Consent (initial) Consent to Treatment I consent to the performance of diagnostic procedures, examinations and rendering of treatment by the medical provider and their designated medical office staff as is deemed necessary in the medical provider s judgment. (Initial) Immunotherapy Treatment Options My treatment options have been explained to me including rapid desensitization versus traditional immunotherapy and the cost difference between these therapies. I understand that rapid desensitization or cluster therapy requires an office visit be charged for each session and that a copayment will be required. (Initial) Insurance Contract I understand that GAAAI has a contract with the insurance carrier which requires them to bill all applicable copayments, co-insurances, and deductibles to the patient/insured as directed by the carrier. Requests for adjustment of these obligations is in direct violation of these insurance contracts and could jeopardize the physician and practices participating provider status. Therefore these requests cannot be accepted. Please make sure you understand your financial obligation and insurance coverage before beginning any treatment. (initial) Financial Policy I authorize the release of any medical information necessary to process an insurance claim on my behalf. I understand that I am financially responsible for all charges and that I am responsible for obtaining any referrals required by my insurance carrier. I request that my medical insurance carrier make any payment directly to Greater Austin Allergy and Immunology for services rendered to me. As a courtesy, my charges will be filed with my insurance carrier; however, I will be billed if the claim is denied or is not paid in a timely manner. I also understand that I am encouraged to check my benefits prior to my appointment and that although I may receive an explanation of benefits, that this is not a guarantee of coverage. 1. There is a $25.00 fee for returned checks. 2. There is a $50.00 fee for MISSED new patient appointments or for new patient appointments CANCELLED less than 24 hours prior to the scheduled appointment. 3. There is a $35.00 fee for missed follow-up appointments and appointments CANCELLED less than 24 hours prior to the scheduled appointment. Uncovered services: We at GAAI provide world-class care for our patients. Accordingly, some of the services we provide have been deemed uncovered by many private insurance carriers. Since these charges are often not covered by insurance, we directly bill these services to our patients. Such noncovered services include (but are not limited to) telephone correspondence(s) over 10 minutes / encounter(s) of any nature, telephone prescription or refill requests and internet/web-based correspondence(s) and encounter(s). (initial) Release of Medical Information I, (print patient name), have read a copy of Greater Austin Allergy s Notice of Privacy Practices. (This document is available at our front desk or at I authorize information to be released to the following individuals: Page9

10 Name: Name: Name: check one: [ Medical] [ Financial] check one: [ Medical] [ Financial] check one: [ Medical] [ Financial] I,, have read and understand the above and agree to the terms stated above. Responsible Party Signature Date GAAI Staff Signature Date Patient Authorization I hereby verify that all information given here is accurate and complete, to the best of my knowledge. Signature Print full name Date Page10

11 Patient Name: Today s Date Patient Authorization for , Automated Calls & SMS Text Communication I hereby give consent to my physician and Greater Austin Allergy to communicate with me via , automated calls & SMS Text. I understand and agree that: I understand that Greater Austin Allergy Asthma & Immunology will use , automated calls & SMS Text for on-emergency purposes and appointment reminders only; I have received a copy of this office s , automated calls, & SMS text policies and have had a chance to ask questions about them; I understand that communications from my physician are not encrypted and that the security of such s cannot be guaranteed; I understand that all communications will be filed in my permanent medical record; and I agree to inform this office in writing if my address and phone number changes. I consent to receive calls and SMS text appointment reminders from Greater Austin Allergy Asthma & Immunology for my protected healthcare and other services at the phone number(s) listed on the front of this form, including my wireless number provided. I understand I may be charged for such calls and texts by my wireless carrier and that such calls may be generated by an automated dialing system. address Cell Phone Number Signature Print full name Date Page11