o Native Hawaiian / Pacific Islander o White

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Joella Gilmore
5 years ago
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PATIENT INFORMATION Last Name: First Name: MI: DOB: / / Gender: M F Height: Weight: Address: City: State: ZIP: Hme Phne: ( ) Cell Phne: ( ) Wrk Phne: ( ) Preferred Cntact Methd: Hme Cell Wrk Scial

1 PATIENT INFORMATION Last Name: First Name: MI: DOB: / / Gender: M F Height: Weight: Address: City: State: ZIP: Hme Phne: ( ) Cell Phne: ( ) Wrk Phne: ( ) Preferred Cntact Methd: Hme Cell Wrk Scial Security#: / / (Wuld yu like t receive ur newsletter?) Y r N Ethnicity (please select ne): American Indian/ Alaska Native Hispanic Native Hawaiian / Pacific Islander Asian White Black / African American Preferred Language: SOCIAL INFORMATION Single Married Divrced Widwed Occupatin (Previus, If Retired): Emplyer: Cigarette/Tbacc: # f Packs Day/Week/Mnth/Scially Quit (Hw lng ag): Never Smked Alchlic Drinks: # f Glasses Day/Week/Mnth/Scially Caffeine: # f cups Day REFERRAL INFORMATION Hw did yu hear abut us? Physician Referred (Name): Friend/Family Member (Name): Advertisement (Type): Other: PRIMARY CARE INFORMATION Primary Care Physician: Phne: D yu release authrizatin fr us t send reprts t yur Physician? Y r N Preferred Pharmacy: Address: Phne: RESPONSIBLE PARTY Last Name: First Name: MI: Address: City: State: Zip: Phne: ( ) Relatinship: Spuse Parent Other (Explain) Primary Insurance: Plicy Hlder: SSN: DOB: Plicy Number: Grup Number: Patient s Relatinship t the Plicy Hlder: Self Spuse Child Other Secndary Insurance: Plicy Hlder: SSN: DOB: Plicy Number: Grup Number: Patient s Relatinship t the Plicy Hlder: Self Spuse Child Other I am authrizing Vein Specialists f Arizna t bill my Health Insurance Cmpany(s) fr services rendered. I understand that in rder t btain Authrizatin fr treatment, my Health Insurance Cmpany(s) must be billed fr my Initial Office Visit and Diagnstic Ultrasund.Once services are billed Vein Specialists f Arizna will be unable t reverse the transactin(s) with my Health Insurance Cmpany. Ifurther understand that in the situatin that my Health Insurance Cmpany(s) fails t pay fr services rendered, I will be financially respnsible t cver the bill. Patient Signature (Printed): Date: Respnsible Party Signature : Date:

2 CURRENT OR PAST MEDICAL HISTORY (Please check all that apply): Nne Anxiety Fever Arthritis Gut Arrhythmias Headache/Migraine Asthma Heart Murmur Bleeding/Bld disrder Hearing Difficulty Breathing Difficulty Hepatitis/Liver Disease Cancer Type: Chest Pain/Tightness High Bld Pressure Depressin HIV/AIDS Diabetes Inflammatry Bwel Dizziness Kidney Disease Leg Trauma Fatigue Mitral Valve Prlapse Nausea/Vmiting/Belly Pain Pulmnary Emblus Rheumatid Disease Seizures Skin Rashes Strke Thyrid Disease Twitching/Paralysis Visual Disturbances Other: PLEASE EXPLAIN ABOVE ANSWERS: ALL CURRENT MEDICATIONS (Prescriptin, Nn-Prescriptins, Vitamins, and/r Herbal): Fr what cnditin(s)/illness d yu take the abve medicatin(s)? ALLERGIES (List all Allergies and Reactins): Nne Latex Allergy: Y r N Skin Tape Allergy: Y r N SURGICAL HISTORY (Please list any/all Surgeries and the year they were perfrmed): Nne FOR WOMEN ONLY: Pregnant Trying t becme Pregnant Breast Feeding Date f last Menstrual Perid: / / Number f Pregnancies: Number f Stillbirths/Miscarriages: Pelvic Pain/Heaviness Veins: Upper Thighs, Vulva, r Labia Area Patient Name (Printed): DOB: Patient Signature: Date: Respnsible Party Signature : Date:

3 HIPAA Privacy Authrizatin Frm I, authrize Vein Specialists f Arizna t disclse and/r release my Prtected Health Infrmatin described belw t: Name(s): DOB: Relatinship: Health Infrmatin t be disclsed (Check all that apply): My Cmplete Health Recrd (Including but nt limited t Diagnsis, Results, Treatment, and Billing). My Cmplete Health Recrd, with the Exceptin f the fllwing: Other (Please Specify): This Medical/Health Infrmatin may be used by the persns I authrized abve t knw and understand my Diagnsis, Treatment, Claims Payment, and/r ther related reasns. This Authrizatin will remain in effect until, at which time this authrizatin will expire. I understand I have the right t revke this authrizatin in writing at any time but any infrmatin given befre that time is cvered by this authrizatin. Patient Name(Printed): DOB: Patient Signature: Date: Respnsible Party Signature: Date: Witness Signature: Date:

4 HIPAA Privacy Rule and Public Health Infrmatin and Liability Waiver This frm is t infrm yu (the patient) that there has been a new criteria established by The Centers fr Medicare and Medicaid Services (CMS), in rder t prmte the cmmunicatin f medical instructins/ infrmatin t all patients. In the prcess f maintaining thrugh cmmunicatin f instructins, it is inevitable that Persnal Health Infrmatin, deemed prtected by the Health Insurance Prtability and Accuntability Act f 1996*, may be furnished t yu in the curse f a meaningful discussin. This infrmatin, nce released int yur care will becme yur sle respnsibility t prtect. By signing this frm yu acknwledge that yu are accepting full respnsibility fr the security and use f yur persnal health infrmatin and that any third party distributin f the infrmatin in yur care is nt the fault r therwise respnsibility f Vein Specialists f Arizna, its physicians r staff. Patient Name (Printed): DOB: Patient Signature: Date: Respnsible Party Signature: Date: Witness Signature: Date: *Guidance frm CDC and the U.S. Department f Health and Human Services* New natinal health infrmatin privacy standards have been issued by the U.S. Department f Health and Human Services (DHHS), pursuant t the Health Insurance Prtability and Accuntability Act f 1996 (HIPAA). The new regulatins prvide prtectin fr the privacy f certain individually identifiable health data, referred t as prtected health infrmatin (PHI).

5 CONSENT TO PHOTOGRAPH AND RECORD FOR CHART AND/OR INSURANCE REQUIREMENT PURPOSES Patient Name: DOB: I hereby authrize Vein Specialists f Arizna and/r attending physicians and staff t: Take and Reprduce Phtgraphs and/r Slides in cnnectin with the Diagnsis, Treatment (including surgical prcedures) r Functinal capacity f the practice.use f material as well as my infrmatin is als authrized fr use in Insurance related dealings, such as: Filing claims, medical necessity, and appeals with the insurance cmpany. I release Vein Specialists f Arizna and its staff and cnsultants frm any and all liability in cnjunctin with the use f stated materials. I als understand that this authrizatin as well as release f liability will remain effective unless revked in writing. Date: Patient Signature: Respnsible Party Signature: Staff member taking phts:

6 Venus HistryQuestinnaire Please explain the reasn fr yu visit with us tday: Hw lng have yu been experiencing these symptms? Year(s) Wh in yur family has suffered frm varicse veins? Previus Venus Treatment: Nne Csmetic Injectins: R L B Laser t Spider Veins: R L B Phlebectmy: R L B Stripping: R L B Sclertherapy: R L B Symptms Occur: Bilateral Legs Right Leg Only Left Leg Only Radifrequency Ablatin (RF): R L B EndVenus Laser (EVLT): R L B Other: When: Where: Right > Left Left > Right Symptms yu suffer in yur legs (Please check all that apply): Visible Veins Pain, Discmfrt, Cramping On a scale frm 0-10: Burning, Itching, Tingling Numbness Restless Leg Syndrme Swelling Easily Bruise Fatigue Skin Disclratin Ankle Ulceratins Bld Clts r Deep Vein Thrmbsis (DVT) Heaviness Bleeding f Veins Calf Pain with regular walks Other: At what time are yur symptms at their wrse? N Symptms During the day When walking During the night When resting After being n feet all day N specific time All the time Other: What daily activities are affected/interrupted by yur symptms? Wrk (t walk r sit) Huse hld chres Exercise Need t take frequent breaks Daily living/quality f life Other: Sleep What methd(s) d yu use/have yu used in the past t alleviate yur symptms? Graduated Cmpressin Hse: >3m>6m >1yr Other NSAIDs: Tylenl r Ibuprfen mg >3m >6m >1yr Frequency Knee High Thigh High Panty Hse Leg elevatins mmhg 30-40mmHg Other: Patient Name (Printed): DOB: Patient Signature: Date:

7 FINANCIAL POLICY Thank yu fr chsing Vein Specialists f Arizna as yur healthcare prvider. We are cmmitted t prviding yu with the best care pssible. The fllwing statement explains ur financial plicy.all patients shuld accurately and cmpletelyfill ut their persnal and insurance infrmatin prir t being seen by the dctr. It is the patient s respnsibility t knw their benefits and cverage prir t the first visit. Failure t d s may result in a higher ut f pcket expense t the patient. We accept Cash, Check, r Credit Cards (Visa, Master Card, Discver, and CareCredit) C-Pays, C-Insurance, and Deductibles must be paid at the time f service Cntracted Insurance: If we are cntracted with yur insurance cmpany we must fllw ur cntract and their requirements. It is the insurance cmpany that makes the final determinatin f yur eligibility. If yur insurance cmpany requires a referral yu are respnsible fr btaining ne. Failure t btain a referral may result in a denial f yur claim. Nn-Cntracted Insurance: Insurance is a cntract between yu and yur insurance cmpany. We are NOT a party t this cntract, in mst cases. If we are nt cntracted with yur insurance cmpany, we will bill yur insurance cmpany as a curtesy t yu. Althugh we may estimate what yur insurance cmpany may pay, it is the insurance cmpany that makes the final determinatin f yur eligibility. Yu agree t pay any prtin f the charges nt cvered by yur insurance. Transferring f Recrds: Yu will need t request in writing, and pssibly pay a reasnable fee if yu re requesting recrds fr persnal purpses. If yu want cpies f yur recrd sent t anther dctr r rganizatin the fee will be waived. The amunt f the fee is dependent n the number f cpies made. Yu authrize us t include all relevant infrmatin. Cancellatin, Rescheduling, and Missing Appintments:Surgery (EndVenus Ablatin/RF) appintments must be cancelled r rescheduled24hrs prir t yur scheduled appintment date t avid a cancellatin/rescheduling fee f $200.00(fr the cst finstruments, supplies, and lss f revenue).all Office visits, Ultrasund appintments, r Sclertherapyappintments must als be cancelled 24hrs prir t yur appintment t avid a $30.00 cancellatin fee.these fees must be received befre yur next appintment will be rescheduled. Re-Billing Fee: A Re-Billing fee f $5.00 will be impsed n each service that is ver (30)days past-due. Payment: Full balance n yur statement is due and payable when the statement is issued and is cnsidered past due if nt paid by the end f the mnth. Returned Checks: If a check is returned t us unpaid by yur bank, we will charge a $25.00 fee. I hereby authrize assignee Vein Specialists f Arizna t release all medical infrmatin necessary t secure payment t my Insurance Cmpany, Attending Physician, and/r Attrney. I hereby assign all medical and/r surgical benefits t include majr benefits t which I am entitled, including medical private insurance and any ther health plan t Vein Specialists f Arizna. I understand that I am fully respnsible fr any and all charges incurred whether r nt paid by my said insurance cmpany. I have been made aware f, read, fully understand, and agree t the terms and financial plicy stated abve. Patient Name (Printed): DOB: Patient Signature: Date: Respnsible Party Signature: Date:

Patient Signature (Printed): Date:

Patient Signature (Printed): Date: PATIENT INFORMATION Last Name: First Name: MI: DOB: / / Gender: M F Height: Weight: Address: City: State: ZIP: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( ) Preferred Contact Method: o Home o Cell o