Secondary Insurance Carrier Name of Insured Member ID# Group # Birthdate of Insured / / Employer SS # of Insured / / Relation to Insured

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Christine Wiggins
6 years ago
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1 PATIENT MEDICAL & PAYMENT INFORMATION SHEET TODAY S DATE Patient Name Date of Birth: / / Age Local Address Social Security # / / City State Zip Code Home Phone # ( ) - Permanent Address Cell Phone # ( ) - Marital Status: Single Married Widowed Divorced Gender: M F Occupation WorkTelephone( ) Place of Employment Work Address Work Telephone ( ) Spouse s Place of Employment Work Address Nearest Relative (not living with you) Relation Nearest Relative s Address Nearest Relative sphone ( ) Person to Contact in Emergency Phone ( ) Primary Physician Phone ( ) Address Do You Have a Medical Insurance? Yes No Primary Insurance Carrier Name of Insured Member ID# Group # Birthdate of Insured / / Employer SS # of Insured / / Relation to Insured Secondary Insurance Carrier Name of Insured Member ID# Group # Birthdate of Insured / / Employer SS # of Insured / / Relation to Insured IF PATIENT IS UNDER 18 OR IF COVERED UNDER PARENTS INSURANCE: Insured Parents Name Phone ( ) Place of Employment Address Payment is expected at time of service. How will you be paying your bill? Cash Check Credit Card May we contact you for medical and financial purposes at all phone numbers listed above? Yes No May we leave your personal health information on your answering machine? voic ? Yes No Special Instructions BGC-914 Rev 03/16

2 BORLAND-GROOVER FINANCIAL POLICY the claim and subsequent payment. Upon each visit, the patient will be asked to provide their insurance cards. OFFICE VISITS: All payment is due and must be paid at the time of the visit to the physician. Each patient will be expected insurance. Additionally, all co-payments must be made at this time. Failure to pay at the time of your visit may result in possible discharge from the practice. MEDICARE WAIVERS: Medicare will only pay for services that it determines to be reasonable and necessary under Section 1862(A) of the Medicare Law. If Medicare determines that a particular service is not reasonable and necessary under Medicare program standards, Medicare will deny payment of that service. Your physician may feel the service is in your medical interest, but you need to know that Medicare is likely to deny payment and by signing this policy you agree to be personally and fully responsible for payment. RETURNED CHECKS: Payments made to Borland Groover Clinic that are not honored by the bank will incur a return check fee of $ If failure to pay the check and fee within 15 days of receiving a return check notice from Borland Groover REFERRALS AND AUTHORIZATIONS: carrier, but the contact lies between you and your insurance company and therefore, you the patient, must obtain our authorization to be seen by the physician. Authorizations will not be obtained the day of your referral appointment, unless in the case of an emergency. COLLECTIONS: my cell phone number. ADMINISTRATIVE: A $10.00 fee requesting a medical letter from their physician. APPOINTMENT NO-SHOWS/CANCELLATIONS: Any established patient who no-shows for their scheduled appointment will be required to pay $25.00 up front before scheduling a new appointment. Any new patient who no-shows for their scheduled appointment will be required to pay $50.00 up front before scheduling a new appointment. Any patient who no-shows for their scheduled procedure will be required to pay $ up front before scheduling a new procedure. Upon showing up for the 2nd scheduled appointment or procedure, the patient will be refunded their money back and we will show up for the 2nd scheduled appointment or procedure we will keep the down payment they provided us. A 48-hour notice must be given to cancel any procedure and a 24-hour notice must be given to cancel an appointment. If the patient fails to provide the appropriate notice, the above policy will be enforced. Any requests for special payment arrangements must be made prior to your visit. You will need to contact the Collections I certify that I have read and accept all terms set forth in this arrangement and I agree to pay BORLAND-GROOVER CLINIC for services rendered. Patient Signature Date

3 Borland-Groover Clinic Acknowledgement of Receipt of Notice & PHI Disclosure Authorization Patient s Full Name Patient s Date of Birth 1. I hereby authorize Borland-Groover Clinic to use or disclose protected health information (PHI) about me to the following person(s). Please write N/A in any of the 3 fields below if not populated with the name of a person: Authorized Individual #1 Authorized Individual #2 Authorized Individual #3 Name Address City, State Zip Phone Number 2. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations. 3. This authorization expires upon written notice from me, and may be revoked at any time. Revocation must be in writing and submitted to the following address: Privacy Officer, 4800 Belfort Rd, Jacksonville, FL I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. 5. NOTICE: I acknowledge that I have had the opportunity to review a copy of BGC s Notice of Privacy Practices ( Notice ). I understand that I am responsible to read this Notice and notify BGC, in writing, of any request for restrictions in the use or disclosure of my PHI. I understand BGC has the right to revise this Notice at any time and will post a copy of the current Notice in the office in a visible location at all times and on their website at BGC will provide me with a copy of its most recent Notice upon my request. 6. I understand the most recent version of this form replaces any previous versions on file in my BGC health record. Previous versions will be voided and PHI release will be based on the current version of this authorization. Signature of Patient OR Date of Patient Signature Signature of Patient s Representative Date of Representative s Signature Description of Authority to Act for the Patient A copy of this completed, signed and dated form must be given to the Individual or other signator. BGC

4 BORLAND - GROOVER CLINIC, P.A. CONSENT TO CARE: I present myself to Borland-Groover Clinic, P.A. for medical care. I hereby authorize and consent to such care, including any tests, examinations, diagnostic procedure, surgical and medical treatment, or outcome of this care. CONSENT TO THE ASSIGNMENT OF INSURANCE BENEFITS AND GUARANTEE OF PAYMENT authorize such physician or organization to submit a claim to my insurance company for payment to me. I authorize any holder of medical or other information about me to release to the insurance company or its intermediaries or carriers any information for this or future claims. I understand I may receive billing for services performed by outside facilities, laboratories, etc. I hereby authorize Borland-Groover Clinic, P.A. to apply any payments made by me and/or on my behalf by a third party payor toward the account referenced. I understand I am responsible for, and agree to pay, upon presentation or demand, any charges that are my responsibility not covered or not paid by any applicable insurance. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for all professional services rendered and consent to calls about nonpaymnet on my house and cell phone numbers. I understand that the physicians of Borland-Groover Clinic, P.A. treat only Gastrointestinal problems, and that my primary care physician is responsible for all other medical care. Information regarding my condition will be made available to the payors and/or providers associated with coordination of my care. I hereby authorize the release of medical, psychiatric, drug and/or alcohol abuse or HIV testing and AIDS information in my records. Written consent must be given if information is to be provided to anyone else (ie, spouse). Verbal information regarding my condition may be given to: relationship. I have read all of the information on this form and have answered the questions. I hereby certify that all information is true and correct to the best of my knowledge. I will notify Borland-Groover Clinic, P.A. of any changes in my health status or the above information. SIGNATURE: DATE SIGNING AS (please check one): PATIENT GUARDIAN GUARANTOR If signed by other than the patient, state the reason the patient was unable to sign RELATIONSHIP TO PATIENT WITNESS

5 Place Sticker Here BGC-463 Rev. 04/16 1 Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Primary Care Physician: Referring: Pharmacy: Pharmacy Phone #: Directions: Please circle any of the following you have personally had during your life: YOUR PAST MEDICAL HISTORY: Asthma COPD Emphysema Blood Transfusion Date: Cancer: Breast Cancer Lung Cancer Colon Cancer Ovarian Cancer Esophageal Cancer Pancreatic Cancer Kidney Cancer Liver Cancer Stomach Cancer Uterine Cancer Other Cancer Congestive Heart Failure Coronary Artery Disease Crohns Disease Ulcerative Colitis Diabetes Mellitus: Type 1 Type 2 Gallstones GERD High Blood Pressure Irritable Bowel Syndrome Liver Disease Pancreatitis Peptic Ulcer Disease Polyps Sleep Apnea CPAP machine Y / N Other ALLERGY REACTION No known allergies LAST MENSTRUAL PERIOD Could you be pregnant? Y / N YOUR PAST SURGICAL HISTORY: Date Appendectomy Artificial Heart Valve Artificial Joint (specify ) Bowel Obstruction Bowel (repair/resection) CABG/Heart Bypass Vessels C Section Gallbladder removal Gastric Bypass Hysterectomy Total Partial Neck Artery/Vascular Surgery Pacemaker Pancreat ic Surgery Surgery for Reflux/Hiatal Hernia Surgery for Ulcers Other MEDIC AL PROBLEMS LIST / REASON FOR VISIT YOUR SOCIAL HISTORY: Occupation Working / Retired Tobacco Status: Former Never Current Type: E-Cigs Qty/day # Yrs Age started Stopped Alcohol: Y/N Drinks/Day Social Former Yr. Stopped Recreational Drug use: Y / N Type: Marital Status: M S D W L Children #: Y/N boys: girls: Directions: Please circle any of the following that exists in your family. YOUR FAMIL Y HISTORY: AGE Adopted Paternal/ TYPE RELATIONSHIP Maternal AGE Cancer, Breast Cancer, Colon Cancer, Ovary Cancer, Uterus Cancer Colon Polyps Crohn s Disease Gallstones Liver Disease Pancreatic Dis. Ulcerative Colitis Ulcers Mother: Alive Y/N If no, cause Father: Alive Y/N If no, cause Sister: Alive Y/N If no, cause Brother: Alive Y/N If no, cause Other Diseases That Run In The Family: Last Influenza Vaccine: Last Pneumonia Vaccine:

6 DIRECTIONS: Please list any over the counter or prescribed medications you currently take. 2 Borland-Groover Clinic MEDICATION LOG NAME: DOB: Drug Name Dosage Start Date Why do you take the medicine? Drug Name Dosage Start Date Why do you take the medicine?

7 3 Borland-Groover Clinic GI REVIEW OF SYSTEMS - FEMALE NAME: DOB: Directions: Have you had any of the following in the last three months? chills fever lack of energy abdominal pain change in bowel habits constipation cold intolerance excessive thirst heat intolerance back pain muscle pain joint pain weight loss nasal congestion sinus infection sore throat short of breath frequent cough wheezing chest pain extremity swelling palpitations diarrhea difficulty swallowing heartburn vomiting blood blood in stool loss of appetite black stool nausea reflux vomiting painful urination blood in urine urinary frequency urinary incontinence vaginal discharge headache numbness tremors sensation of room spinning anxiety increased stress contact allergy hives itching rash easy bleeding easy bruising enlarged lymph glands asthma food allergies altered/weakened immune system seasonal allergies bloating uncontrolled bowel movements gas hemorrhoids yellow skin painful swallowing rectal bleeding

Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Primary Care Physician: Pharmacy: Pharmacy Phone #:

Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Primary Care Physician: Pharmacy: Pharmacy Phone #: PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Referring: Pharmacy: Pharmacy Phone #: Place Sticker Here Directions: Please circle any of the following you have personally