FLOYD CARDIOLOGY Demographic Information

Transcription

1 FLOYD CARDIOLOGY Demographic Information Patient Information Last: First: MI: SS #: Sex: DOB: Street Address: City: State: Zip: Home Phone: Work Phone: Address: Employer: Occupation: Responsible Party Name (If Different From Above) Last: First: MI: DOB: Street Address: City: State: Zip: Phone #: SS #: Emergency Contact Last: First: Relationship: Home Phone: Work Phone: Mobile: Street Address: City: State: Zip: Nearest Relative Not Living With You Last: First: Relationship: Home Phone: Work Phone: Mobile: Street Address: City: State: Zip: How Did You Hear About Floyd Cardiology? My Doctor Referred Me Friend/Family Internet/Web Site Article/Print Primary Insurance Carrier Information Name of Carrier: Claims Mailing Address: Insured Name: DOB: SS #: Relationship: Insurance Phone #: Policy #: Group #: Secondary Insurance Carrier Information Name of Carrier: Claims Mailing Address: Insured Name: DOB: SS #: Relationship: Insurance Phone #: Policy #: Group #: Referring Physician: Phone #: Primary/Family Physician (PCP): Phone #:

2 NEW PATIENT HEALTH QUESTIONAIRE DATE: / / Name: Gender: M / F Date of Birth: Age: Referring Doctor: REASON(S) FOR VISIT 1. Chest Pain 7. Heart Murmur 2. Shortness of Breath 8. Dizziness / Fainting 3. Palpitations 9. Pre surgical Evaluation 4. Heart Failure 10. Abnormal Rhythm 5. Stroke or TIA 6. Other (Please Specify): PREVIOUS HEART HISTORY 1. Pacemaker / ICD Year: 2. Heart Cath / Angioplasty / Stent Year: 3. Coronary Bypass Surgery Year: 4. Other Heart Procedures: RISK FACTORS 1. High Cholesterol NO YES Year: 2. High Blood Pressure NO YES Year: 3. Diabetes NO YES Year: 4. Cigarette Smoker NO YES (Quit)Year: 5. Parent/Sibling with Heart Disease NO YES Who? SURGICAL HISTORY (LIST PREVIOUS OPERATIONS). NO YES 1. Year: 2. Year: 3. Year: 4. Year: MEDICAL HISTORY 1. Asthma NO YES 2. Stomach Ulcers NO YES 3. Hepatitis NO YES 4. Other:

3 MEDICATIONS Please bring actual bottles NAME DOSE FREQUENCY DRUG ALLERGIES MEDICATIONS REACTION SOCIAL HISTORY Occupation: Marital Status: Married Divorced Widowed Single Exercise Program: Diet: Alcohol Intake: REVIEW OF SYSTEMS CHRONIC COUGH YES NO ANEMIA YES NO EMPHYSEMA YES NO ARTHRITIS YES NO KIDNEY STONES YES NO DVT (LEG CLOT) YES NO IBS (Irritable Bowel) YES NO DIALYSIS YES NO LOW THYROID YES NO AIDS / HIV YES NO GLAUCOMA YES NO FRACTURES YES NO SEIZURES / EPILEPSY YES NO CATARACTS YES NO HEARTBURN/REFLUX YES NO LEUKEMIA YES NO PULMONARY EMBOLISM YES NO CANCER YES NO

4 SIGNATURES RELEASE AD HIPPA AUTHORIZATION FORMS Credit Policy for Floyd Cardiology All services rendered by Floyd Cardiology are charged directly to the patient. We will be happy to file all necessary insurance forms at no charge and credit their payments to your account. Unless we are contracted with your insurance carrier as a participating provider to accept what they approve, your deductible percentage not covered by the carrier is due at the time of service. Managed care co-pays are due the time of service. If you do not have insurance, payment arrangements must be made prior to service. If you first saw Dr. Floyd in the hospital, payment arrangements must be made immediately after hospital discharge for an office follow-up. Payment of your charges is ultimately your responsibility and you, as the patient, agree to comply with our policy. Signature: Date: Consent of Professional Services/Information Release/Assignment of Benefits I consent to treatment/services necessary for the care of my present condition. I authorize holder of medical and other information about me to release any information needed to determine benefits. I hereby assign, transfer and set over to Floyd Cardiology my assignment of benefits for reimbursement of services. This consent/authorization/assignment will remain in effect until revoked by me, the patient, in writing. A photocopy of this assignment is considered as valid as the original. In understand that I am financially responsible for any charges not paid by said insurance. Signature: Date: Insured Signature: Date:

5 Disclosure of Medical/Financial Information To Family and Friends Name of Patient: Date of Birth: SS #: I, the undersigned, hereby authorize Floyd Cardiology to disclose information from my medical or financial records to the following people: Name: Relationship: Contact Information: Type of Information to be released: Medical Financial Both Name: Relationship: Contact Information: Type of Information to be released: Medical Financial Both This Authorization is given freely with the understanding that, 1) I may revoke this authorization at any time, but not retroactively, by letting Floyd Cardiology know in writing, and 2) Floyd Cardiology, its employees, officers, and the physician are hereby released from legal responsibility or liability for the disclosure of the information I authorized previously. Patient s Name (Printed): Date: Patient (or representative) signature: Social Security Number (for ID only): Witness Signature: Witness Name (Printed): Date:

6 Floyd Cardiology Associates Financial Policy Thank you for selecting our practice for your cardiovascular care. Our goal is to provide you with the highest quality treatment and service. Your complete understanding of your financial responsibilities is an essential element of your care. If you have any questions about the following policy, please do not hesitate to ask our staff. Billing & Insurance Patients are responsible for payment at the time of service. We accept cash, check, and Major Credit Cards. We are contracted with many insurance plans and will accept assignment of benefits. As a courtesy, we will file all claims, including secondary insurance, to the plans with which we participate. Please inform us of any special requirements in your plan. We encourage our patients to understand their policy and to be proactive in ensuring that claims are paid. You are ultimately responsible for any charges incurred by you for treatment from Floyd Cardiology Associates. All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be not covered, or you do not have an authorization, you will be responsible for the complete charge. Patients are encouraged to contact their plans for clarification of benefits prior to services being rendered. You must inform the office of all insurance changes, authorization referral requirements, and address changes. In the event the office is not informed before care is rendered, you will be responsible for any charges that are denied. You may receive a separate bill for laboratory or pathology services from an off-site lab for any tests your physician may order. Please discuss any billing errors or discrepancies with that laboratory. Cancellations and Missed Appointments We receive many requests from patients who have urgent need for care. As a result we kindly request that you allow at least 24-hours notice of a cancellation. We call all of our patients two days prior to the day of their scheduled appointment in order to confirm the appointment. If we do not receive 24-hours notice, we reserve the right to charge a cancellation fee of up to $75.00 to the patient or responsible party. Patients with multiple missed appointments and/or cancellations may be discharged from our practice. Late Arrivals In an effort to serve our patients in a timely manner, we ask that you arrive on time for your scheduled appointment. In the event you are running late, please call our office. If you are more than 15 minutes late to your scheduled appointment, you may be asked to reschedule. Returned Check Fee There will be a $25.00 charge for all returned checks.

7 Collection Fee If your account is turned over to our collection agency, you will be responsible for the collection fee charged to us by the agency in addition to your outstanding balance. I have read and understand the financial policy, and I agree to be bound by its terms. I understand and agree that such terms may be amended in the future by the practice. Signature of Patient or Responsible Party Date Printed Name of Patient Date of Birth