Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX Phone: Fax: Address: City: ST: ZIP:

Transcription

1 Haroon Rehman, MD 3200 Talon Drive. Suite 300 Richardson, TX Fax: Patients General Information Last Name: First Name: Patient s SSN: of Birth MM/DD/YYYY: / / Age: Sex: M/F Race (optional): Patient s address: Home Mobile Address: City: ST: ZIP: May we contact you by PHONE for APPOINTMENTS NEWSLETTERS? Y/N How did you learn about us? Reason for visit: Primary Care Physician name: Location: Employer name: Street: City: ST: ZIP: Primary insurance: Traditional /HMO/ PPO/ Medicaid/ Medicare/ Other (circle one) Company: Group number: Employee ID / Member ID: Secondary Insurance: Traditional/ HMO/ PPO/ Medicaid/ Medicare/ Other (circle one) Company: Group number: Employee ID / Member ID:

2 Haroon Rehman MD Talon Drive. Suite 300 Richardson, TX Fax: HEALTH QUESTIONNAIRE Name: : Medication Please list any medications that you currently take regularly (including non-prescription) Allergies Please list any allergies to medications, food or other Medical History Illnesses/ Conditions Do you have or you ever had any of the following Anemia Anxiety Arthritis Asthma Birth Defects Cancer (type: ) Colitis Concussion Diabetes Emphysema Heart attacks/ Heart Disease High Blood Pressure High Cholesterol Kidney Disease Low Blood Sugar Mitral Valve Prolapse/ murmur Osteoporosis Pneumonia Rheumatic fever Seizure Disorder Sexually Transmitted Disease Stroke Thyroid Disorder Tuberculosis Gynecological History (Women only) Are you pregnant? Are you breast feeding? Last menstrual period How many pregnancies have you had? How many children have you had? At what age did you start having periods? Have you had a mammogram? Last time you had a pap smear? Last clinical breast examination? Family History Have any blood relative ever had any of this following? Relative (mother, father, sister, etc.) Bleeding problems Cancer (type ) Convulsions Diabetes Heart Attacks Heart Disease High Blood Pressure Mental illness /suicide Seizures Stroke Other Surgical Procedures/Hospitalization Serious Injuries Childhood Diseases Chickenpox Measles Mumps Polio other: When, if ever, did you last have any of the following: Cholesterol check Colonoscopy Tetanus (Last shot) EKG/electrocardiogram Flu Vaccine Prostate exam

3 Social History Do you drink alcohol? Yes / No How many per week? Do you or have you ever smoked or chewed tobacco? Yes / No Packs per day Quit? When? Do you or have you ever used recreational drugs? Yes / No Type: Do you drink caffeine daily? Yes / No How much? Do you exercise regularly? Yes / No How often? Are you married? Yes / No Do you have children/dependents at home? Yes / No How many? What is your highest level of education? Do you have a living will or advance directives? Yes / No Review of Symptoms Please circle any of the following that you recent experience. General Fatigue, Fever, Hopelessness, Hot flashes, Night sweats, Recent weight loss or gain Skin Change in pigmentation, Hives, Itching, Rashes ENT Change in vision/hearing, Congested nose, Ringing in ears, Ear discharge, Hearing loss, Nose bleeds, Chronic sinus problems Breast Lumps in breast, Nipple discharge, Erosion around nipple area Respiratory Difficulty breathing, Frequent cold/coughing, Shortness of breathing Cardiac Chest pain, Difficult walking 2 blocks, Palpitations, Swelling of the feet/ankles Gastrointestinal Abdominal pain/cramping, Blood or black stool, Change in the bowel habits or appetite, Frequent diarrhea, Frequent heartburn /gas / bloating, Vomiting blood, Nausea, Difficulty swallowing Genitourinary Difficulty urinating, Frequent urination, Loss of bladder control, Burning urination, Vaginal discharge, Change in urine stream/ smell/ color Musculoskeletal Joint pain or swelling, Difficulty walking, Muscle cramping or weakness Neuropsychiatric Prior treatment for depression/psychiatric care, Fainting spells, Convulsions, Headaches, Dizziness, Poor concentration, Loss of interest in daily activities, Difficulty sleeping Hematologic Easy bruising, Excessive bleeding after cuts, Slow healing after cuts, Lumps in armpit or groin area

4 FINANCIAL POLICY OUR PRACTICE FINANCIAL POLICY We are dedicated to providing you with the best possible care and service, and regard your understanding of our financial policy as an essential element of your care and treatment. To assist you, we have the following financial policy. If you have any question please feel free to discuss them with our staff. Unless other arrangements have been made in advance by either you or your health coverage carrier, full payment is due at the time of service. YOU INSURANCE We have made prior arrangements with many insurers and other health plans. We will bill those plans with which we have an agreement and will collect any required co-payment at the time of the service. The co-payment will be collected when you arrive for your appointment. In the event your health plan determines a service to be not covered, you will be responsible for the complete charge. In that event we will bill you and payment is due upon receipt of that statement. If you have insurance coverage with a plan with which we do not have prior agreement, we will prepare and send the claim for you, on an unassigned basis. In this case, your insurer will send the payment directly to you. Therefore charges for your care and treatment are due at the time of service. We will also bill your health plan for all service we provide in the clinic. Any balance due is your responsibility and is due upon receipt of a statement for our office. Please be advised that there will be a $36 service charge for any returned checks. MINOR PATIENTS For all services rendered to minor patients, the adult accompanying the patient is responsible for the payment. MISSED APPOINTMENT In order to provide the best possible service and availability to all our patients, it is our policy to charge our office visit fee for any appointments not cancelled at least one day prior. Please call us early as possible if you know you will need to reschedule your appointment. CONSENT TO TREAT I consent to treatment as necessary or desirable to the care of the patient named below, including but restricted to whatever drugs, medicine, performance of operations and conduct of laboratory, x-ray, or other studies that may be used by the attending physician, his nurse or qualified designate. I further understand that the qualified designate in the same case will be the assistant to the Primary Care Physician, all also called an MA. I also acknowledge full responsibility for the payment of such services and agree to pay for them, in full, at the time of service. If the physician must use a collection agency/attorney or court to collect its charges, then I will pay reasonable attorney fees and costs incurred in collecting same regardless of insurance coverage. I hereby authorize payment directly to Dr. Haroon Rehman of the medical expense benefits otherwise payable to me but not to exceed my indebtedness to said Physician on account of the enclosed charge. I have read and understand the financial policy of the practice and I agree to the bound by its terms that such terms may be amended from time-to-time by the practice. Signature of patients or responsible party if minor Printed name of patient 3200 Talon Drive Suite 300 Richardson, TX 75082

5 FINANCIAL AGREEMENT In consideration of the patient receiving services from the Physician, I agree: I am responsible for all expenses for treating the patient. Payment of charges is due at the time of the appointment. If the Physician files my insurance for me, I agree to pay for non-covered insurance benefits, co-insurance, co-pays, and deductibles. Patient Signature Responsible Party s Signature (Parent/Guardian of Minor) AUTHORIZATION TO RELEASE INFORMATION & TO PAY BENEFITS I authorize the Physician to release any of my medical information, including drug and alcohol and HIV positive test results, to my insurance company(s), as needed to process my insurance claim. I authorize my insurance company to make payments directly to the Physician for covered medical and/or surgical services. Patient Signature Responsible Party s Signature (Parent/Guardian of Minor) _