HAMID MOAYAD, D.O., P.A. PATIENT REGISTRATION FORM, PLEASE PRINT

Transcription

1 HAMID MOAYAD, D.O., P.A. PATIENT REGISTRATION FORM, PLEASE PRINT Date: Date of Birth: Age Sex Home Number: Name: Cell Number: Home Address: Additional Number: City: Relationship to Add Number Above: State: Zip: Social Security Number# Marital Status: M D W S Primary Insurance Company Name: ID # Type of Insurance Policy? Private Insurance: Employer Group Policy: HMO PPO Indemnity POS POS II Choice Plus EPO Address for Claims: Insurance Phone # for Eligibility: Insured Name: D.O.B. of Insured if not the patient: Insured Employer Name: Policy or Group Number: Secondary Insurance Company Name: ID # Type of Insurance Policy? Private Insurance: Employer Group Policy: HMO PPO Indemnity POS POS II Choice Plus Plus Address for claims: Phone # for Eligibility: Insured Name: _ D.O.B. if insured if not the patient: Insured Employer Name: Policy or Group Number: Health History Medical Allergies Medication Taking Now High Blood Pressure Yes No Diabetes Yes No Prolonged Bleeding Yes No Easy Bruising Yes No Pregnant Now Yes No Significant Medical History/ Surgery History Reason for Seeking Medical Attention I hereby assign all my medical benefits, including Major Medical, Private Insurance and any other health plans to Hamid Moayad, D.O. P.A. I hereby authorize said assignee to release all information necessary to secure payment. I understand that I am financially responsible for all charges. All payments are to be made to: HAMID MOAYAD, D.O., P.A HARWOOD RD STE B BEDFORD TEXAS, Patient or Guardian Signature: Date

2 DR MOAYAD IS AN OUT OF NETWORK PROVIDER FOR PPO INSURANCES ONLY OFFICE POLICY: We appreciate your patronage. The purpose of our policy is to inform patients of their responsibility before their appointment. If you do not understand any part of the policy below, please ask our office staff. RELEASE OF MEDICAL INFORMATION: I hereby authorize Hamid Moayad, D.O. to release information to my insurance carriers, other physicians and facilities concerning my illness and treatments. I certify that I have given correct and complete information with regards to my insurance coverage. ASSIGNMENT OF BENEFITS: I hereby assign Hamid Moayad, D.O. all payments of medical services rendered. I understand that I am responsible for any amount not paid by my insurance company, including diagnostic services, evaluation, laboratory tests, non-covered services, copays, deductibles, and co insurance balances. INSURANCE POLICY: It is the policy of this office to collect copays and deductibles at the time of your appointment. It may also be necessary to collect payment in full for some lab services that is not covered by insurance. FIRST INITIAL VISIT FOR PATIENTS PAYING CASH WITH NO INSURANCE: Igenex Lab Testing for Lyme Igg, Igm has to be paid separately by check or credit card made out to Igenex. The check or credit card information will be sent with your lab test the same day. Cash Pay Patients Initial Cost: Your initial cost for an office visit is $400 to $500. Follow up visits will be $200 to $300 and will work with you on payments with an equitable resolution. FIRST INITIAL VISIT FOR PATIENTS WITH INSURANCE: Igenex Lab Testing for Lyme Igg, Igm, has to be paid separately by check or credit card made out to Igenex. Insurance won t cover this test. The check or credit card information will be sent with the lab test the same day. Your Initial visit if you have insurance will be $400 to $500. Follow up visits will be $200 to $300. We will bill your insurance company for your office visit and labs and depending on the reimbursement from your insurance we will work with you on payments with an equitable resolution with deductibles, co-insurance and non-covered services. REFERRALS AND IN-NETWORK APPROVALS: It is the patient s responsibility to keep up with referrals and in network approvals. Dr. Moayad is an out of network provider. If your PPO insurance reimbursement is low we will ask you to help get Dr. Moayad approved to see you at a higher rate of pay and also to keep patient cost down. You will be responsible for keeping up with current approvals for Dr. Moayad to be paid in network with your PPO insurance. GENERAL CONSENT TO TREAT: I authorize and direct Hamid Moayad, D.O., P.A. to treat my medical condition in a way he may determine advisable for my wellbeing. I acknowledge that the practice of medicine is not an exact science and no guarantees have been made to me as to the outcome of my treatment. When you arrive for your visit, date and sign that you understand our office policy, release of medical information, assignment of benefits, insurance policy. Initial visit for cash patients, Initial visit for patients with insurance Referrals and in network approvals, and general consent to treat. PATIENT SIGNATURE: Date: GUARDIAN SIGNATURE: Date: WITNESS FROM DR MOAYADS OFFICE Date:

3 Lyme Symptom Check List Patient Birth Date Risk Profile (Please Check) Infested Area Frequent Outdoor Activities Fishing Hiking Camping Gardening Hunting Ticks Noted on Pets Do you remember being bitten by a tick? No Yes When? Do you remember having the Bull s Eye Rash? No Yes Any other rash? No Yes Have you had any of the following? Check all YES Answers Unexplained Skin Changes: Fevers Sweats Chills Flushing Unexplained Weight Change: Weight Loss Weight Gain Fatigue Tiredness Unexplained Hair Loss Swollen Glands Sore Throat Testicular Pain Pelvic Pain Unexplained Menstrual Irregularity Unexplained Milk Production Unexplained Breast Pain Urinary Problems: Irritable Bladder Bladder Dysfunction Sexual Difficulties: Sexual Dysfunction Loss of Libido (desire) Change in Bowel Function: Constipation Diarrhea Upset Stomach Chest Pain Rib Soreness Shortness of Breath Cough Heart Palpations Pulse Skips Heart Block Any history of heart murmur or valve prolapse? Yes No Joint pain or swelling? Yes No List joints: Stiffness: Joints Neck Back Muscle Pain Cramps Twitching: Face Other Muscles Headache Neck Creaks Neck Cracks Neck Stiffness Tingling Numbness Burning Stabbing Sensations Facial Paralysis (Bells Palsy) Eyes/Vision: Double Vision Blurry Pain Increased Floaters Ears/Hearing: Buzzing Ringing Ear Pain Increased Motion Sickness Vertigo Lightheadedness Wooziness Poor Balance Difficulty Walking Tremor Confusion Difficulty Thinking Difficulty with Concentration Difficulty Reading Forgetfulness Poor Short Term Memory Disorientation (Getting Lost) Going to Wrong Places Difficulty with Speech Difficulty Writing Mood Swings Irritability Depression Disturbed Sleep: Too Much Too Little Early Awakening Exaggerated Symptoms or Worse Hangover from Alcohol

4 MEDICATION PATIENT FOLLOW UP FORM Date: Name: NAME STRENGTH FREQUENCY 1. ANTIBIOTICS: Herxheimers Yes No Effective Yes No Herxheimers Yes No Effective Yes No 2. PAIN MEDS: 3. ANTI INFLAMMATORY: 4. ANTI DEPRESSANT: 5. ANTI SEIZURE 6. OTHER MEDICATIONS:

5 LYME PATIENT FOLLOW UP FORM Date: Name: Please circle on a scale of 0 through 4. 0 being not present and 4 meaning severe symptoms: None Minimal Mild Moderate Severe 1. Chills or mild fever Sore Throat Lymph node pain Muscle weakness Muscle pain Headaches Joint pain Specify which joints: Does joint pain move around? Yes No 8. Neurological symptoms 1. Light bothers eyes Forgetfulness Irritability Confusion; difficulty thinking Depression Inability to concentrate Brief periods of visual spots or loss of vision Sleep disturbance Too Much Too Little 10. Fatigue Since my last visit I feel: Same Better Worse

6 Patient Comfort Assessment Guide Name: Date: 1. Where is your pain? 2. Circle the words that describe your pain. aching sharp penetrating throbbing tender nagging shooting burning numb stabbing exhausting miserable gnawing tiring unbearable Circle One: Occasional Continuous What time of day is your pain the worst? Circle one. Morning Afternoon Evening Nighttime 3. Rate your pain by circling the number that best describes your pain at its worst in the last month. No Pain Pain as bad as you can imagine 4. Rate your pain by circling the number that best describes your pain at its least in the last month. No Pain Pain as bad as you can imagine 5. Rate your pain by circling the number that best describes your pain at its average in the last month. No Pain Pain as bad as you can imagine 6. Rate your pain by circling the number that best describes your pain right now. No Pain Pain as bad as you can imagine 7. What makes your pain better? 8. What makes your pain worse? 9. What treatments or medicines are you receiving for your pain? Circle the number to describe the amount of relief the treatment or medicine provide(s) you. a) No Complete Treatment or Medicine (include dose) Relief Relief b) No Complete Treatment or Medicine (include dose) Relief Relief c) No Complete Treatment or Medicine (include dose) Relief Relief d) No Complete Treatment or Medicine (include dose) Relief Relief

7 10. What side effects or symptoms are you having? Circle the number that best describes your experience during the past week. a. Nausea Barely Severe Enough b. Vomiting Barely Severe Enough c. Constipation Barely Severe Enough d. Lack of Appetite Barely Severe Enough e. Tired Barely Severe Enough f. Itching Barely Severe Enough g. Nightmares Barely Severe Enough h. Sweating Barely Severe Enough i. Difficulty Thinking Barely Severe Enough j. Insomnia Barely Severe Enough 11. Circle the one number that describes how during the past week pain has interfered with your: a. General Activity Does Not Completely b. Mood Does Not Completely c. Normal Work Does Not Completely d. Sleep Does Not Completely e. Enjoyment of Life Does Not Completely f. Ability to Concentrate Does Not Completely g. Relations with Does Not Completely Other People

8 HAMID MOAYAD, D.O., P.A. NEUROLOGY AMERICAN ACADEMY OF NEUROLOGY AMERICAN COLLEGE OF NEUROPSYCHIATRY AMERICAN SOCIETY OF NEUROIMAGING CONFIDENTIAL PATIENT AGENDA Dear Patient: To help you make best use of your time with Dr. Moayad, please list the questions you would like to discuss during your appointment Signature Date