INTERNAL MEDICINE GROUP OF TAMPA BAY

Transcription

1 INTERNAL MEDICINE GROUP OF TAMPA BAY ID# Patient Information Patient Name: DOB: Gender: M F Married: Y N Ethnicity: African-American Asian Caucasian Hispanic Native-American Pacific Islander Other Decline to answer Address: Home Phone: Cell Phone: Preferred language: Employer: Work #: Employer Address: Insurance Company: Insurance Claims Address: Policy ID#: Group #: Policy Holder: Relationship to Patient: Policy Holder DOB Secondary Ins Policy: Spouse/Significant Other: Phone: Emergency Contact: Phone: How did you hear about us? If referred, please specify: AUTHORIZATION AGREEMENT I AGREE TO PAY IN FULL FOR ALL SERVICES RENDERED TO MYSELF, MY SPOUSE, AND/OR MY DEPENDENTS, BY THE MEDICAL STAFF AT INTERNAL MEDICINE GROUP OF TAMPA BAY. I HEREBY AUTHORIZE THE RELEASE OF MEDICAL INFORMATION TO REVIEW AND PROCESS INSURANCE CLAIMS. I HEREBY AUTHORIZE ANY INSURANCE COMPANY TO PAY THE PROCEEDS OF ANY BENEFITS DUE DIRECTLY TO RAJANI P. SHAH, M.D.. A COPY OF THIS AGREEMENT CAN BE CONSIDERED AS AN ORIGINAL FOR MEDICARE & INSURANCE PURPOSES. Patient Signature: Date:

2 HISTORY AND PHYSICAL ASSESSMENT ID# Patient Name: Date: DOB: Age: Sex: Male Female Address: Home Phone: Cell Phone: Fax: Employer: Occupation: Ph#: Marital Status: (circle one) Married Widowed Single Divorced Separated Number of children Do you live alone? Yes No Do you have a living will? Yes No Nearest Relative: Relationship: Ph#: Primary Language: Race: Religion: Previous Physician: Last Seen: Phone #: Address: Previous Dentist: Last Seen: Phone #: Address Were you hospitalized in the past year? If yes, date(s): Reason: Have you ever had surgery? If yes, dates Reason: List any past accidents, injuries, or major illnesses not mentioned above. Please include dates: Have you ever had a blood transfusion? Yes No If yes, date(s): Do you have any food allergies? Yes No If yes, list:

3 Patient Name: Do you have allergies to any medications? Yes No if yes, list the medication and the reaction to the medication: List any medication(s) you take: Medication Dosage Time/Day Personal Habits/ Lifestyle: (check all that apply) Do you smoke cigarettes? Yes No If yes, how long have you smoke for? # of cigarettes per day: Have you ever smoked? Yes No If yes, how many cigarettes per day Quit date: Do you drink alcohol? Yes No If yes, how much, and how often? Wine Beer Hard Liquor Do you drink caffeine? Yes No If yes # of cups per day: Exercise: 3 or more times a week less than 3 times a week none Are you sexually active? Yes No If yes, do you practice safe sex? Yes No Past Drug Use: marijuana cocaine LSD heroin speed other Present Drug use: marijuana cocaine LSD heroin speed other Exposure to domestic violence? Yes No

4 Patient Name: Review of Systems: (check any symptoms you have, or have had in the past) General: Depression Dizziness Fainting Forgetfulness Frequent Chills Frequent Fevers Frequent Headaches Frequent Sweats Loss of Sleep Loss of Weight Nervousness Skin: New Growth Change in Mole Bruise Easily Scar(s) Rash Hives Itching Sore(s) Ears: Ringing in Ears Loss of Hearing Earache Ear Discharge Eyes: Change in Vision Double Vision Blurred Vision Vision-Flashes Vision-Halos Eye Discharge Nose: Nose Bleeds Sinus Pressure Hay Fever Mouth/Throat: Bleeding Gums Difficulty Swallowing Persistent Cough Cardiovascular: Chest Pain Difficulty Breathing High Blood Pressure Irregular Heartbeat Poor Circulation Rapid Heartbeat Low Blood Pressure Swelling of Ankles Varicose Veins

5 Patient Name: Gastroenterology: Poor Appetite Bloating Bowel Changes Constipation Diarrhea Excessive Hunger Excessive Thirst Hemorrhoids Indigestion Rectal Bleeding Gas Stomach Pain Vomiting Vomiting Blood Nausea Urology: Blood in Urine Frequent Urination Infrequent Urination Lack Bladder Control Painful Urination Muscle/Joint/Bone: (pain, weakness, or numbness) Feet Hands Arms Legs Back Hips Shoulders Men: Erection Difficulty Lump in Testicle(s) Penis Discharge Sore on Penis Lump in Breast Women: Breast Lump Abnormal PAP Painful Intercourse Nipple Discharge Hot Flashes Vaginal Discharge Bleeding Between Periods Severe Menstrual Pain Date of last menstrual cycle: Date of last Pap smear: Have you had a mammogram? Date of last mammogram: Are you pregnant? If yes, how many weeks? How many live births have you had? How many miscarriages/abortions?

6 Patient Name: List any specialty doctor(s) you see, or have seen: Doctor Specialty Phone # Family History: CAUSE LIVING OR DECEASED OF DEATH AGE CANCER TB SICKLE LIPIDS HEART HIGH DIABETES CELL DISEASE BP FATHER MOTHER SIBLING SIBLING SIBLING CHILD CHILD Social History: (needs community service for) Meals on Wheels Shopping Eating Bathing Alzheimer's Support Other Activities of Daily Living: (needs assistance with) Ambulating Dressing Bowel/Bladder emptying Other Uses: Cane Walker Wheelchair Hearing Aid Visual Aid Oxygen Nebulizer Other

7 INTERNAL MEDICINE GROUP OF TAMPA BAY ID# *Financial Policy* Thank you for choosing INTERNAL MEDICINE GROUP OF TAMPA BAY as your healthcare provider. The physician and staff members at INTERNAL MEDICINE GROUP OF TAMPA BAY are committed to the excellent treatment of all of our patients. PRIVATE INSURANCE POLICY Patients are responsible for the annual deductible, co-insurance, and any co-pay insurance requirement, per patient insurance contract, at the time of his/her office visit. Patient account balance is due at the time of service unless a payment arrangement is made prior to appointment. Patient is also responsible for any difference between the amount of our billed fee, and the amount received from your insurance company (indemnity insurance, as well as coverage under a letter of protection). We are happy to assist all patients in billing his/her insurance company for all procedures. We will request the insurance company to remit the payment directly to our office. Before making an appointment with our practice, the patient is responsible for contacting his/her insurance company to verify that we are a healthcare provider per his/her insurance plan. INSURANCE COVERAGE It is the patient s responsibility to contact their insurance and have Dr. Rajani Shah listed as his/her primary care physician. If Dr. Shah is not listed as the patient's primary care physician, his/her insurance may not cover treatment; in this case, the patient will be responsible for the billed amount. Please make sure Dr. Shah is listed as the primary care physician before making an appointment with our practice. I am aware that Dr. Shah does not accept MEDICAID as a primary or secondary insurance coverage. I understand that I will be responsible for any payment due for service provided which are not covered by my insurance. MISSED APPOINTMENTS We understand that unforeseen events happen that may prevent a patient from making his/her appointment; however patients will be charged a non-refundable $25.00 no-show fee after his/her second missed appointment. To avoid this fee, kindly call 24 hours prior and cancel or reschedule any appointment(s). As a courtesy, patients will receive a reminder phone call from our office the business day prior to his/her appointment. I have read the Patient Financial Policy and agree to abide by its terms. I authorize my insurance company to forward the Explanation of Benefits (EOB) and related payments to Rajani P. Shah, M.D. Patient Signature Date

8 INTERNAL MEDICINE GROUP OF TAMPA BAY ID# ***UPDATED OFFICE POLICIES*** Effective January 1, 2014 As part of our ongoing efforts to make your experience with us a pleasant one, and to ensure your continued satisfaction with our services, we have adopted some additional office policies. Please read carefully, and initial the following updates. Feel free to speak with our staff should you have any questions or concerns about these policies. Blood work is required before all physical exams. If a patient misses a pre- physical blood work appointment, their physical exam will be canceled, and will need to be rescheduled. Payment for any required insurance co-pay, self-pay charge, and/or any outstanding balance on a patient s account will be required at time of visit. A $25.00 non refundable no show fee will be applied to the patient s account for an appointment missed without a 24 hour notice to cancel. This fee is not covered by insurance. It is the sole responsibility of the patient. As a consideration to other patients, patients who are 20 minutes or more late for their appointment will be rescheduled to another time. All prescription requests require a minimum 24 hour turnaround time for processing. Thank you for your cooperation. We look forward to your continued care with us. Patient s Name: Patient s Signature: Date: Witness Signature: Date:

9 INTERNAL MEDICINE GROUP OF TAMPA BAY ***INSURANCE COVERAGE NOTICE*** I, understand that the following may not be covered by my insurance; laboratory testing, including but not limited to Labcorp, Quest Diagnostics, ECG/EKG, vaccinations, and/or injection therapy. I understand I will be responsible for 100% of the billed cost for any of the above tests/procedures not covered by my insurance. I also understand that it is my responsibility as the patient, and the policy holder to contact my insurance company to inquire as to what services are covered. I also understand that any lab work done at INTERNAL MEDICINE GROUP OF TAMPA BAY invoice(s) I receive for lab fees are from the lab directly, therefore all billing issues need to be addressed with the lab directly. I as a patient of Internal Medicine Group of Tampa Bay understand that my physical exam must be scheduled a year and a day from my last physical in order for the exam to be covered by insurance. I also understand that it is my responsibility to confirm the date of my last physical exam before scheduling. If my appointment is scheduled before the one year and one day required by my insurance, I understand that I will be financially responsible for the appointment and all services provided. Patient Signature Date Witness Signature Date Cross Creek Blvd Suite B Tampa, FL Phone: (813) Fax: (813)

10 INTERNAL MEDICINE GROUP OF TAMPA BAY *PERMISSION TO RELEASE PROTECTED MEDICAL INFORMATION* The doctor and staff at INTERNAL MEDICINE GROUP OF TAMPA BAY cannot discuss your protected health information (PHI) with anyone other than yourself unless you authorize us to do so. Please list below the names(s) of the individual(s) you authorize our office to discuss your care with. Your PHI will be disclosed to the individual(s) listed below until you notify us otherwise in writing. This authorization will remain in effect for one year unless otherwise specified. I understand by signing this form I authorize the release of all medical records, which may include psychiatric information, genetic counseling (Acquired Immunodeficiency Syndrome), and/or may include the result of an HIV test. I understand that my (PHI) may be used or disclosed under this authorization, and may be subject to re-disclosure, thus my PHI may no longer be protected by law. By signing this authorization I expressly consent to the release of information as designated above. I understand I must notify INTERNAL MEDICNE GROUP OF TAMPA BAY, in writing, where the original authorization is retained, in order to discontinue this consent to release. I, give my permission for the following person (s) to receive my medical information. Name: Relationship: Signature Date

11 INTERNAL MEDICNE GROUP OF TAMPA BAY I, authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to contact me by home phone, cell phone, fax, and/or , and leave detailed messages regarding all test results, and/or reminders for future scheduled appointments. Patient Home Phone # Patient Cell Phone # Patient Private Fax # Patient address If there are any changes to the contact information previously provided to INTERNAL MEDICINE GROUP OF TAMPA BAY I understand that it is my responsibility to provide timely updates to my contact information on file. If I wish to update any information, or revoke permission for messages to be left regarding test results, I must contact INTERNAL MEDICINE GROUP OF TAMPA BAY in writing during normal business hours. Please initial below to indicate your authorization Yes I authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to leave messages. No I do not authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to leave messages. Signature Date Print Name

12 INTERNAL MEDICINE GROUP OF TAMPA BAY PRIVACY NOTICE Effective January 1, 2014 A copy of INTERNAL MEDICINE GROUP OF TAMPA BAY'S Privacy Practices is available at or at our office. Acknowledgment of receipt of Notice of Privacy Practices: I, have received notice of Privacy Practices from INTERNAL MEDICINE GROUP OF TAMPA BAY which has been updated for the new Omnibus Rule and has an effective date of September 23, We encourage you to review it carefully. Our notice of Privacy Practices is subject to change. If we change our Notice, you may obtain a copy at the front desk. The notice describes: the ways the Privacy Rule allows our practice to use and disclose protected health information. How our practice will get your permission, or authorization, before using your health records for any other reason. the practice's duties to protect health information privacy. the patient's privacy rights, including the right to complain to HHS and to the covered entity if you believe your privacy rights have been violated. how to contact our practice for more information and to make a complaint. I understand that the Privacy Practices may be revised from time to time and that I have the right to receive an updated copy upon request. Patient/Legal Guardian Signature Date