Authorization For The Release Of Medical Information
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- Joel McCormick
- 6 years ago
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1 Authorization For The Release Of Medical Information Patient s Name: DOB: Date: Doctor you are seeing today: I give my consent and authorize Vascular and Vein Specialists at The Longstreet Clinic to release any medical records including but not limited to records, reports, notes, chart notes, letters, photographs, test reports or results (including physical test results, pathology test results, laboratory test results, x-rays, MRI & CAT scans, EKGs, etc), financial information (including insurance information and/or billing statements), and referral letters. I also consent and authorize the discussion of medical records and information pertaining to me or my treatment. I understand I am authorizing the release of this information to the following individuals: This release of information is intended to include records maintained in my maiden or other names as follows: I understand Vascular and Vein Specialists at The Longstreet Clinic may not make my completing and signing this authorization a condition of my treatment. I understand that I am authorizing the use or disclosure of my protected health information as described above. I understand that information released may no longer be protected under the HIPAA rules and regulations. I understand that I may be charged for any copies provided. I may revoke this authorization at any time in writing. I have read, understand and agree to the above stated policy. Patient Signature Date - 1 -
2 Today s Date: Name: DOB: Sex: Male Female What doctor are you seeing today? Referring Physician s name and phone number Primary Care Physician s name and phone number Reason for today s visit Allergies and reactions Current medications and dosages including over the counter medication: PAST MEDICAL HISTORY: Cardiovascular: Chest pain Heart Attack Atrial Fib CHF Heart disease(cad) Hypertension High Cholesterol TIA Stroke Heart Murmur Heart Valve Respiratory: Gi: Shortness of breath Asthma COPD TB GERD Gallbladder Disease Hepatitis Constipation Diarrhea Diverticular Disease GI bleeding Endo: Type 1 Diabetes Type 2 Diabetes Hypothyroidism Hyperthyroidism
3 Name DOB MEDICAL HISTORY continued: Heme/Oncology: DVT Cancer Anemia Blood Disorder Pulmonary Embolism Msk: Skin: Gyn: Gu: Psych: Neuro: Sleep: Arthritis Rheumatoid Arthritis Osteoarthritis Backache Obesity Skin Disorder Eczema Psoriasis Rashes Infertility Recent Pregnancy UTI Acute Renal Failure Chronic Renal Failure Incontinence BPH Depression Anxiety Bipolar Disorder Schizophrenia Seizures Alzheimer s Migraines Dementia Parkinson s Disease Insomnia Sleep Apnea Other medical history not listed: SURGICAL HISTORY: Cardiovascular: CABG Valve Surgery Stent Placement Cardiac Cath Pacemaker Resp: GI: Gyn: Endo : Lung Surgery Appendectomy Cholecystectomy Hernia Repair Weight Loss Surgery C-Section Tubal Ligation Hysterectomy D&C Thyroidectomy Parathyroidectomy Gu: TURP Prostatectomy Bladder Surgery Lithotripsy Nephroectomy (Left/Right) Breast: Breast Biopsy Mastectomy Breast Reduction Breast Augmentation Breast Reconstruction Neuro: Spine Surgery Laminectomy Craniotomy Heent: Sinus Surgery T&A Cataracts Oral Surgery Msk: Knee Replacement Hip Replacement Shoulder Surgery Arthroscopy
4 Name DOB SURGICAL HISTORY cont: Vascular Surgery: Carotid Endarterectomy (Left/Right) Carotid Stent (Left/Right) Angiogram Angioplasty Endovascular repair of AAA Open repair of AAA Repair of Thoracic Aneurysm Carotid Bypass Carotid Subclavian Bypass Bypass Aorto-Iliac Bypass Aorto-Bifemoral-Iliac Bypass Aorto-Femoral or Bifemoral Bypass Femoral-Popliteal Permcath AV Fistula (Left/Right) AV Graft (Left/Right) Dialysis patients ONLY: Dialysis center and location: Davita Fresenius Medical Care Other Dialysis days: Monday, Wednesday, Friday Tuesday, Thursday, Saturday Nephrologists: Who is your kidney doctor? Unspecified Vascular Surgery ( ) Social History: Tobacco use: Do you smoke? No (non-smoker) yes quit If yes, do you smoke: cigarettes cigars pipe vapor/electric If quit, when did you last smoke: (year) Alcohol use: None Rarely Occasionally Frequently Daily ( Number of drinks) Exercise: Type and Frequency Occupation: Marital Status: Married Single Widowed Significant other Living Situation: At Home Alone At Home with Family Assisted Living Nursing Home Family History (LIST Mother, Father, Sibling, etc.): Heart disease/heart attack Hypertension Stroke Diabetes Aneurysm DVT/Blood Clot Cancer
5 FINANCIAL POLICY We participate in most insurance plans, including Medicare and Medicaid. We do not file to general liability or homeowner s insurance. You and your insurance company are responsible for your bill. Knowing your insurance benefits is your responsibility. Any questions concerning your coverage should be directed to your insurance company. If your primary insurance company requires a co-payment, you must make the co-payment at time of service. Failure to pay your copay at time of service will result in a billing fee of $ Please remember that we are contractually obligated by your insurance company to collect your copay at time of service. The balance of your charges will be billed. Payment in full of patient portion will be expected with receipt of your statement. Proof of current, valid insurance must be provided at time of service. If you do not provide this information, you will be considered a self-pay patient. Self-pay patients are required to make an advance payment on their office visit charge. The advance payment amount will be based on the services provided. Please ask about your advance payment responsibility when making your appointment Failure to pay your advance payment at time of service will result in a billing fee of $ You will be billed for the balance of your charges. Payment in full will be expected with receipt of your statement. Failure to receive your statement does not relieve you of your financial obligation. It is your responsibility to notify us of any changes in your billing information. We accept cash, checks, money orders and major credit cards. Returned checks are subject to a $25.00 return check fee. Past due accounts are subject to our collections process. Patient Name (or responsible party) Date C:\Users\emwillia\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\8C3TI2KW\FINANCIAL POLICY REVISED SEPT doc
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New Patient Information Patient Title Dr. Mr. Mrs. Ms. Miss Last Name First Name M.I. Address Apt/Ste # City State Zip Date of Birth / / Age Male Female Home Phone Cell Phone Is it ok to leave a detailed
JOHN R. SIMPSON, D.D.S, M.D., F.A.C.S.
JOHN R. SIMPSON, D.D.S, M.D., F.A.C.S. EAR, NOSE AND THROAT HEAD AND NECK SURGERY ENDOSCOPIC SINUS SURGERY (3D Guided) Balloon Sinuplasty, Surgery for Sleep Apnea NORTHEAST GEORGIA EAR, NOSE, THROAT HEAD
Financial Policy 5-10 Adult
Financial Policy 5-10 Adult Patients are responsible to provide current information for billing and insurance and notify the business office of any changes in a timely manner. Patients that do not have
Patient Name LAST First Middle Date of Birth Age Sex ( ) Male ( ) Female. Patient Mailing Address: Apt: City State Zip. Home Phone ( ) Cell Phone ( )
Patient Information Patient Name LAST First Middle Date of Birth Age Sex ( ) Male ( ) Female Social Security ( ) Married ( ) Single ( ) Divorce ( ) Separated ( ) Widowed Please use your physical mailing
PATIENT INFORMATION. Race: Ethnicity:
PATIENT INFORMATION Last name: First: MI: Today s Date: SS#: Mailing Address: Date of Birth: City: State: Zip: Sex: Primary Phone: Home Work Mobile Secondary Phone: Home Work Mobile Tertiary Phone Home
812 N.E. 25th Avenue Suite A
Carl M. Salvati, D.P.M. 812 N.E. 25th Avenue Suite A Ocala, Florida 34470 Phone 352-351-4444 Date: / / Name: DOB: - - Age: Sex M F Phone ( ) - S.S.# - - Marital S M D Widow Address: City State Zip Email:
Demographic Information
Demographic Information Patient Name: Mailing Address: City: State: Zip Code: Home Phone: OK to Leave Message: Brief Extended Cell Phone: OK to Leave Message: Brief Extended Work Phone: OK to Leave Message:
LAST NAME FIRST M.I. DATE OF BIRTH SEX RESPONSIBLE PARTY STREET ADDRESS CITY STATE ZIP CODE RESPONSIBLE PARTY PHONE ( ) LANGUAGE ETHNICITY RACE
CIGNA ONSITE HEALTH PATIENT INFORMATION FORM Check one of the following: Attach copy of front and back of Insurance card All Cigna Insurance Other Insurance (Any Non-Cigna) FFS/Self Pay PATIENT INFORMATION
PATIENT SIGNATURE: DATE:
NAME: DOB: DATE: PRIMARY CARE PHYSICAN: REFERRING PHYSICAN: REASON FOR VISIT TODAY: E- MAIL: PHARMACY: PHARMACY TELEPHONE #: MEDICATIONS (Include nonprescription drugs, Vitamins, and Herbal drugs) Do you
Financial Responsibility
Financial Responsibility This is an agreement between Florida Medical Clinic, P.A., a Florida Corporation, as a creditor, and the Patient/Debtor named on this form. In this agreement the words I, you,
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM PATIENT DATA Last Name: First Name: Middle Initial: Date of Birth: Social Security [last 4 digits]: Female Male Occupation: Employer: PREFERRED METHOD OF CONTACT Home phone: Preferred
for / / at in (Provider name) (date) (time) (location)
Welcome to our practice. We strive to make the registration process go as quickly for you as possible on the day of your appointment with for / / at in (Provider name) (date) (time) (location) In order