PATIENT INFORMATION FIRST NAME MARITAL STATUS S M D W OCCUPATION STATE ZIP CODE ASSIGNMENT OF INSURANCE BENEFITS

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Meryl Sullivan
5 years ago
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The Ayre Clinic for Contemporary Medicine 11S250 Jackson Street, Suite 101, Burr Ridge IL 60527 / 630-321-9010 / fax: 630-321-9018 / www.contemporarymedicine.

1 The Ayre Clinic for Contemporary Medicine 11S250 Jackson Street, Suite 101, Burr Ridge IL / / fax: / PATIENT INFORMATION PATIENT INFORMATION LAST NAME FIRST NAME MARITAL STATUS S M D W ADDRESS GENDER F M STATE ZIP (OPTIONAL) PATIENT EMPLOYMENT INFORMATION EMPLOYER OCCUPATION STATE ZIP CODE ADDRESS IN CASE OF EMERGENCY, WHO SHOULD BE NOTIFIED? NAME RELATIONSHIP YOUR PHARMACY NAME HOW DID YOU LEARN ABOUT CONTEMPORARY MEDICINE? Physician Referral Internet Friend or Acquaintance Advertisement Newsletter Book or other Publication ASSIGNMENT OF INSURANCE BENEFITS The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or my dependents. I further expressly agree and acknowledge that the signature on this document authorizes my physician to submit claims for benefits, services rendered, or for services to be rendered without obtaining my signature on each and every claim to be submitted for myself and/or my dependents, and that I will be bound by my signature as through the undersigned had personally signed the particular claim. I hereby authorize my insurance company to pay and Print Name of Insured hereby assign directly to The Insured all benefits, if any. I understand that I am financially responsible for all charges incurred. Authorized Signature of Insured or Legal Representative Date

2 THE AYRE CLINIC FOR CONTEMPORARY MEDICINE 11S250 JACKSON STREET, SUITE 101, BURR RIDGE IL INSURED INFORMATION PERSON WITH INSURANCE SELF PARENT NO INSURANCE SPOUSE OTHER INSURED S LAST NAME INSURED S FIRST NAME SS# Please fill out the section below ONLY IF THE INSURED PERSON IS DIFFERENT THAN THE PATIENT INSURED S LAST NAME INSURED S FIRST NAME INSURED S ADDRESS SS# STATE ZIP CODE EMPLOYER EMPLOYER ADDRESS OCCUPATION STATE ZIP CODE PRIMARY INSURANCE INFORMATION NAME OF INSURANCE COMPANY INSURANCE COMPANY ADDRESS STATE ZIP ID OR POLICY # GROUP # SECONDARY INSURANCE INFORMATION NAME OF INSURANCE COMPANY INSURANCE COMPANY ADDRESS STATE ZIP ID OR POLICY # GROUP # INSURED S NAME

3 Date: Contemporary Medicine Health History Questionnaire Name D.O.B / / Phone (H) (W) Address City State ZIP Past Medical History (conditions & dates) Past Surgical History (procedures & dates) Family History - Heart disease Cancer Diabetes Tuberculosis Others (Please provide relevant details below: - living - deceased - age/age at death - conditions) Father: Mother: Brothers: Sisters: Personal History - Occupation Relationship status - S M W D Spouse s Occupation Children: M/Ages F/Ages Smoker Y N Ex-Smoker Y N Smoking History: cigs/day X yrs. Alcohol ounces/week Coffee/Tea cups/day Pop cans/day Do you feel you eat a well balanced diet most of the time? Y N Medications and Dosages: Supplements & etc. Allergies: Medications Foods Inhalants & etc. Symptom Inventory: - For all of the following that apply to you, please indicate whether your symptoms are: Mild (1) - Moderate (2) - or Severe (3) hair loss skin rashes (itchy hands feet trunk perineum/crotch ) easy bruising visual disturbances (blurred see bright lights ) itchy eyes earaches reduced hearing buzzing in ears sinus pain nose bleeds runny nose nasal obstruction/mouth breathing sore tongue sore gums pressure/temperature sensitive teeth clicking of jaw orthodontic braces tooth extractions root canals dentures frequent sore throats hoarseness ulcers/sores in mouth cold sores stiff/sore neck shortness of breath (on exertion lying down ) cough (with sputum or with blood ) wheezing snoring chest pain average times per week (on exertion at rest ) palpitations cold hands/feet pain in calves after walking swelling of ankles fainting spells dizzy spells varicose veins loss of appetite difficulty swallowing heartburn sour hiccups nausea vomiting weight gain weight loss abdominal pain abdominal bloating burping passing gas diarrhea constipation blood in stools hemorrhoids hernias frequent bladder infections incontinence (spontaneous with coughing/sneezing ) get up at night to urinate (# ) decrease in force/flow discharge back pain arthritic pains (where ) difficulty sleeping panic attacks depression headaches memory loss frequent loss of temper numbness/tingling (where? ) fatigue dizziness balance problems other symptoms not listed? * For women * menstrual periods - regular irregular pain/cramps days of flow length of cycle date of last menstrual period pain or bleeding during or after intercourse Are you presently using some form of birth control? Y N Which one? For how long? Any other previous form of birth control? Y N Which one? For how long? Have you ever been on BCPs? Y N For how long? When? / to / (approx.) How many pregnancies? how many live births? any miscarriages or abortions? Recent Stress History - In the past 12 months, have you experienced any of the following major stresses? marriage divorce death of a spouse other death in the family loss of or change of job moving your place of residence significant financial loss significant financial gain automobile accident hospitalization

4 Consent for Release of Medical Records Date Physician/Institution Address I hereby request transfer of portions of my medical records, as specified below to: The Ayre Clinic for Contemporary Medicine Thomas L. Hesselink, MD 11S250 Jackson Street, Suite 101 Burr Ridge, IL ph: fax: Admission Hx and Px Hospital Discharge Summary Typed Consultations Pathology Reports Other MRI Printed Reports X-Ray Printed Reports CT/PET Printed Reports Tumor Markers Mammogram Reports Records will include all materials from the following dates: Reason for release Continuing Care Referral Change of Insurance Other Patient Name (printed) Patient/Representative Signature Date of Birth This release will expire within one year of being signed

5 OUR FINANCIAL POLICY Thank you for choosing Contemporary Medicine as your health care provider. The following is a statement of our Financial Policy, which we require you read and sign prior to your treatment. We require payment at the time of service for medical care provided to you. You are responsible for payment regardless of your insurance provider s determination of usual and customary rates. All services provided through Contemporary Medicine are considered out-of-network services. We do not submit claims to Medicare. As a courtesy to you, we will submit all charges to your insurance provider. Any and all insurance benefits resulting from these claims will be assigned to you. It is possible to receive out-of-network reimbursement, depending on your plan and coverage. We cannot make any guarantees of reimbursement. For your convenience, we accept personal checks, VISA, MASTERCARD, and DISCOVER. I hereby declare that I have read the Financial Policy and understand and accept all of the above statements: Signature: Date:

Birth Date: Age: Sex: Ethnicity: Carrier: Cardholder's Name: Carrier: Cardholder's Name:

Patient Information Patient's Last Name: First: MI: Social Security Number: Birth Date: Age: Sex: Ethnicity: Street Address: City: State: ZIP Code: Home Phone: Cell Phone: Work Phone: E-Mail Address: Referring