CARDIOVASCULAR PREVENTION AND THERAPUETICS OF NY, PLLC Dr s James Blake, Daniel Krauser and Alex Mauskop
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1 CARDIOVASCULAR PREVENTION AND THERAPUETICS OF NY, PLLC Dr s James Blake, Daniel Krauser and Alex Mauskop DATE: NAME: SEX: AGE: HOME ADDRESS: APT: CITY: STATE: ZIP CODE: ADDRESS: DATE OF BIRTH: SS# MARTIALSTATUS: HOME PHONE: CELL: WORK: PHARMACY NAME/ ADDRESS: PHARMACY PHONE NUMBER: EMPLOYER: NEAREST RELATIVE/FRIEND: PHONE NUMBER OF NEAREST RELATIVE/FRIEND: REFFERRED BY: PHONE # ADDRESS: OTHER PHYSICIANS ATTENDING TO YOU AT THIS TIME: 1. PHONE: 2. PHONE: REASON FOR CONSULATION: ALLERGIES (PLEASE INCLUDE REACTIONS CAUSED): PRESENT MEDICATIONS (IF NEEDED CONTINUE ON REVERESE SIDE): MEDICATION STRENGTH FREQUENCY
2 NAME: SEX: DATE: REVIEW OF SYSTEMS: DO YOU HAVE ANY YES NO PLEASE DESCRIBE: OF THE FOLLOWING SYMPTOMS: Frequent Cough Shortness Of Breath Chest Pains Palpitations Murmur History of Rheumatic Fever Heart Burn Indigestion Diarrhea Constipation Blood In Stool Pain on Urination Blood in Urine Frequent Urination Joint Pains/ Arthritis Anemia Thyroid Problems Anxiety Other conditions not mentioned FAMILY HISTORY: ARE YOUR PARENTS ALIVE? MOTHER (YES/NO) FATHER (YES/NO) LIST ANY HEALTH CONDITIONS THEY MAY HAVE; (IF DECEASED, PLEASE INDICATE THEIR AGE AT THAT TIME AND CAUSE IF KNOWN); MOTHER FATHER If you have any siblings please indicate their health conditions if any: Please indicate any serious/important health conditions that may have affected your extended family; i.e. aunts, uncles, grandparents:
3 MEDICAL AND PHARMACY MEDICATION RELEASE FORM I hereby authorize the release of my medical records and/or information to Dr. Blake, Dr. Krauser, and/or Dr. Mauskop. I also authorize the physicians to access the pharmacological data base in order to review the medications I have received from other physicians. Signed: Date:
4 PATIENT HIPAA CONSENT FORM I understand that I have certain rights to privacy regarding my protected health Information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); Obtaining payment from third party payers (e.g. my insurance company); The day-to-day healthcare operations of your practice. I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. Signed this day of 20. Print Patient Name Signature Relationship to Patient Cardiovascular Prevention and Therapeutics of NY James A. Blake, MD Daniel G. Krauser, MD Alex Mauskop, MD 133 East 58 th Street Suite 301/304 New York, NY 10022
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6 Insurance Information Primary Insurance: Name of Insured: Policy#: Group#: Policy or Group Name: Relation to Patient: SELF SPOUSE OTHER: (Please circle one) Secondary Insurance: Name of Insured: Policy#: Group#: Policy or Group Name: Relation to Patient: SELF SPOUSE OTHER: (Please circle one) Assignment of Benefits: I request payment from authorized companies and agencies such as Medicare, Blue Cross, Oxford, HMO s and all commercial insurance benefits be made to Cardiovascular Prevention and Therapeutics of NY, PLLC for any professional services rendered by the physicians. Signed: Date: Release of Information: I authorize the release of my medical record and/or information to the above companies and agencies. I also, authorize the physicians to access the pharmacologic database in order to review the medications I have received from the other physicians. Signed: Date:
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8 HELP US HELP YOU! As a courtesy Cardiovascular Prevention and Therapeutics of NY, PLLC are willing to set aside their usual practice of receiving full payment at the time of service. Your signature below authorizes your insurance company to directly reimburse Cardiovascular Prevention and Therapeutics of NY, PLLC for their services. On receiving payment our office will notify you of any outstanding balance for which you are responsible. However, despite your authorization, sometimes your insurance may send the payment directly to you. The check is intended to reimburse Cardiovascular Prevention and Therapeutics of NY, PLLC for their services as detailed in the explanation of benefits accompanying the check. Should you receive a check that is intended for Cardiovascular Prevention and Therapeutics of NY, PLLC, and the check should immediately be endorsed over to Cardiovascular Prevention and Therapeutics of NY, PLLC and returned to our office so that your account may be credited. Thank you for your cooperation. My signature below authorizes my medical insurance company to pay Cardiovascular Prevention and Therapeutics of NY, PLLC directly for their services. I understand, however that I am personally responsible for all charges. Signed: Date
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Arizona Retina Associates
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ADVANCED VEIN & VASCULAR SOLUTIONS Board Certified Vascular Surgeons
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GENERAL INFORMATION. Scott D. Kazdan, D.O., LLC 601 N. Flamingo Road, Suite 209 Pembroke Pines, FL Phone (954) Fax (954)
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WELCOME TO GOTHAM FOOTCARE, PC Thank you for selecting our podiatric care team. We will strive to provide you with the best possible foot care. To help us meet all of your foot care needs, please fill
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Surgical Group of Gainesville, PA
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LONG ISLAND BARIATRIC, PLLC
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