Kipp M. Robins, MD * Aaron Paxman, PA * Family Audiology TODAY S DATE PATIENT S NAME: BIRTHDATE

Transcription

1 Kipp M. Robins, MD * Aaron Paxman, PA * Family Audiology PATIENT S NAME: TODAY S DATE BIRTHDATE WAS THERE A DOCTOR WHO REFERRED YOU? No Yes If yes, who Who is your Family or Primary care doctor? WHAT are we seeing you for HOW LONG has this been going on? Height Weight Marital status: Married Single Widowed Divorced Do you currently smoke? NO YES- how long? Former smoker? NO YES Do you drink alcoholic beverages? NO YES ALLERGIES-medication environmental: CIRCLE any of the following you currently or recently have had: Allergies Blurry vision Canker sores Change in appetite Chills Chronic hoarseness Diabetes Difficulty speaking Difficulty swallowing Dizziness Double vision Ear drainage Ear fullness Ear pain Ear pressure Ear(s) plugged Enlarged neck nodes Enlarged thyroid Eye pain Eye tearing Fever Frequent colds Frequent sore throats Headaches Hearing loss Migraines Mouth blisters or ulcers Neck pain or stiffness Neck limited motion Night sweats Current MEDICATIONS/vitamins w/dosage: Past medical problems: Previous surgeries-what when: Family members we have seen, what did we see them for, and their relationship to patient? Any Immediate family members with health problems, cause of death, relationship to patient: Painful swallowing Parathyroid problems Recurrent ear infections Ringing in ears Sinusitis Sore lips Thyroid problems Tonsillitis Vertigo Weight gain Weight loss OTHER:

2 Chart No. PATIENT INFORMATION Date: Name: Preferred Name: Mailing Address: Apt# City State Zip Street Address: Apt# City State Zip Preferred Phone:( ) Alternate Phone:( ) Date of Birth: / / Sex: M F Marital Status: Married Single Other Preferred Language: Ethnicity: Hispanic Non-Hispanic Race: Caucasian Native American Asian African American Pacific Islander Other Social Security No.: - - Employer: Employer Phone: ( ) Primary Care Physician: Whom We Can Thank for Referring You to Us: RESPONSIBLE PARTY INFORMATION (If different from patient.) Name: Relationship to Patient: (Circle One) Spouse Father Mother Other: Mailing Address: Apt# City State Zip Preferred Phone:( ) Date of Birth / / Social Sec. No.: - - Employer: Employer Phone: ( ) PERSON TO CONTACT IN CASE OF EMERGENCY (If possible, list someone with a different phone number than your own.) Name: Relationship to Patient: (Circle One) Spouse Father Mother Other: Home Phone: Mobile Phone: INSURANCE INFORMATION 1) Primary Insurance Company: Claims Address: City State Zip Group No. ID No. Relationship of Patient to Insured: (Circle One) Self Spouse Child Other Policy Holder: Date of Birth: / / 2) Secondary Insurance Company: Claims Address: City State Zip Group No. ID No. Relationship of Patient to Insured: (Circle One) Self Spouse Child Other Policy Holder: Date of Birth: / / (CONTINUED ON BACK) GM

3 MEDICAL INFORMATION RELEASE I acknowledge that I have been provided a copy of the NOTICE OF PRIVACY PRACTICES of Central Utah Clinic, P.C. (the Clinic ) and that the Clinic may release all or portions of my medical record to me, and to people or companies responsible to pay the charges for my care, such as my insurance or health benefits companies, or worker s compensation carriers. I further acknowledge that the Clinic may disclose my patient information to referring or treating health care providers, and for payment and health care operations. I hereby authorize the Clinic to obtain my medical information from other health care entities and providers, including but not limited to, copies of lab results, diagnostic test reports, films/images, and other clinic information deemed necessary by the Clinic physicians or representatives. I understand that I may inspect my protected health information, request more information, and revoke this authorization, as permitted by the federal privacy regulations and in accordance with the Clinic s privacy policy. Patient/Responsible Party Signature: Date: CONSENT FOR TREATMENT I hereby consent to the medical treatment, diagnostic and laboratory tests, and other procedures, which the physician(s) may deem advisable in treatment of my case (or as legal guardian for patient). The Clinic will determine the proper disposition of any tissues, parts, or body fluids consistent with state and federal laws. This agreement will remain in effect until I choose to revoke it in writing. Patient/Responsible Party Signature: Date: CREDIT AND FINANCE CHARGE POLICY AND AGREEMENT I hereby authorize any benefits due me to be paid directly to the Clinic, 1055 North 500 West, Provo, Utah I understand and agree that I am financially responsible for all deductible amounts, co-insurance, non-covered services or services deemed as nonmedically necessary by my third party insurance carrier. I agree that I am responsible for satisfying any conditions necessary for insurance or health benefits. A finance charge (1.5% per month/apr 18%) may be added to any amount for which payment has not been received within 60 days from the date of the statement on which the amount first appears. I hereby agree to pay a service charge of $20.00 for each check or other instrument tendered by me but returned to this facility. Additional service charges may be levied for accounts placed with thirdparty collection agencies, or failure to make necessary co-payments at the time of service. It is understood and agreed that if I fail to pay this account in accordance with policy, then I will pay all reasonable attorney fees and other costs incurred for collection of this account. In consideration for medical services rendered, I (we) acknowledge that I (we) have received notice of the Clinic s financial policy and agree to pay for said medical services according to such terms. Patient/Responsible Party Signature: Date: MEDICARE PATIENT AGREEMENT (Required by Medicare for all Medicare claims) Entitlee s Name Medicare Subscriber Number I hereby request that payment of authorized Medicare benefits be made either to me or on my behalf to CENTRAL UTAH CLINIC, P.C. for any services furnished me by that provider. I authorize any holder of medical information about me to release to Center for Medicare Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. This authorization is in effect until I choose to revoke it in writing. Signature: Date: Employee Signature: Date: GM

4 "#$%%%%%%%%%%%% KIPP M. ROBINS, MD Provo ENT 2230 North University Parkway #9B * Provo, UT * "#$%'()*#()+*,'-$.(+,'/,%0)%1$# "234563' / '()*+,-.+/+(,.0,,-./ (5)16.5,1371,4()84/.+9(53715)(+83,1(539(*, ,-.:+12304#(,10.; <3*,-(+1=.4(*,(6(,-.)(77(>15?@ :#% ' A(*834;52<575==2>5=(584359>.+15? (+2( ?3+615?3//(15,8.5, ;,.9,+.9*7,9;.,0BC.15?9*+.,(156103,.,-./ D9538.;/-(5.5*8C.+;356/.+9( ?B?*#',(.'+"$#%#'+@AB5ACD6;E'#DF3B5FD;;DG46>H8 :#%' <?12.4(*84/ (5,(6190*9984,+.3,8.5,(+0(561,1(5>1,-(':I5J=D6@=H>-(16.5,1)4, ) C.+9;)+1.569(+6.91?53,.603+.?12.+9B K$K <?12.4(*84/ (5,(6190*9984,+.3,8.5,(+0(561,1(5>1,-'):3B5FD;;DG46>I5J=D6@=H8 -DJAB4;MJ56N6M5JOPQI;52=5;4=3RD3BI2J563= "(+,#'+L"($#'+LS1($/,('%,S'(+1$#8%%%%%%%%%%%%%%%%%%%%%%%%%%%%$5;234D6=B4I3DI234563%%%%%%%%%%?4365==5MRE%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%/235%%%%%%%%%%%%%%%%%%

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