KNIGHTSBRIDGE INTERNAL MEDICINE & CARDIOLOGY, INC. New and Current Patient Information Sheet

Transcription

1 KNIGHTSBRIDGE INTERNAL MEDICINE & CARDIOLOGY, INC. New and Current Patient Information Sheet PATIENT INFORMATION Name: (First)(MI) (Last)_Date: _ Date of Birth Age Sex: M F Marital Status: S M W D Race: _ Ethnicity: Language: Address: (Street) (City, State, ZIP) Home Phone #: Cell Phone # Social Security #: Employer: Work #: Employer s Address: Referring Physician: If Student, Full/Part Time: EMERGENCY CONTACT INFORMATION Name: Relationship to patient: Home Phone #: Cell Phone #: May We Release Protected Health Information To This Individual: Yes No ADDITIONAL CONTACT (OPTIONAL) Name: Relationship to patient: Home Phone#: Cell Phone#: May we Release Protected Health Information To This Individual: Yes No ADVANCE DIRECTIVES INFORMATION Do You Have A Living Will? Yes No (If yes, provide copy to the front desk) Do You Have A Durable Power Of Attorney For Health Care? Yes No (If yes, provide copy to the front desk) Do You Have A Do Not Resuscitate? Yes No (If yes, provide copy to the front desk) PRIMARY INSURANCE INFORMATION Medicare #: Medicaid #: Insurance Co: Phone #: Insurance Address: Group #:Policy Holders Certificate or I.D.#: Insured s Name: Relationship to Patient: Self Spouse Dependent Insured s Employer: Phone #: Employer s Address: Policy Holder s Social Security #: Date of Birth: Sex: M F If the patient is covered by another insurance policy, please complete the following information for coordination of benefits. This information will enable your insurance company to process your claim more quickly. Thank you! SECONDARY INSURANCE INFORMATION Insurance Co:Phone #: Insurance Address: Group #: Policy Holder Certificate or I.D. #: Policy Holder s Name: Relationship to patient: Self Spouse Dependent Insured s Employer: Phone #: Employer s Address: Policy Holder Social Security #: Date of Birth: Sex: M F 08/16

2 KNIGHTSBRIDGE INTERNAL MEDICINE & CARDIOLOGY, INC. MEDICAL PAYMENT AND AUTHORIZATION I HEREBY AUTHORIZE: Knightsbridge Internal Medicine & Cardiology, Inc. to provide diagnostic and treatment services to me. All rendered services, including any changes or updates in existing treatment, will be discussed with me prior to their implementation. Knightsbridge Internal Medicine & Cardiology, Inc., to release relevant information acquired in the course of my treatment. Any physician, hospital, or medical care facility to provide all information on my medical history and treatment to Knightsbridge Internal Medicine & Cardiology, Inc. Payment directly to Knightsbridge Internal Medicine & Cardiology, Inc. for my surgical and/or medical benefits which are payable to me under the terms of my insurance. Photocopies of this form to be as valid as the original. NOTICE TO MEDICARE PATIENTS: We accept assignment on MEDICARE claims, therefore the twenty percent of Medicare s approved amount is the patient s responsibility and we are required to collect this portion of the fee. FINANCIAL POLICY Our office is committed to providing the best possible care. If you have medical insurance, we want to help you receive your maximum allowable benefits. To achieve these goals, we need your assistance, and your understanding of our payment policy. Payment for service is due when services are provided, if applicable. Insurance plans require that we collect a co-payment at the time of service if indicated. Returned checks may be subject to additional collection fees. Charges may also be made for missed appointments. Delinquent accounts may be subject to interest charges. Please realize that: 1. Your insurance is a contract between YOU, your employer, and the INSURANCE COMPANY. We are not party to that contract. If you need clarification concerning your benefits, please contact your insurance company representative. 2. Our fees are considered usual, customary and reasonable by most companies and are covered up to the maximum allowance determined by each carrier. This applies only to companies who pay a percentage (such as 60 or 80%) of U.C.R. as defined as usual, customary and reasonable fees, with whom we have a contract. 3. Not all services are a covered benefit in all contracts. Please check with your carrier if you have any questions regarding coverage, especially when testing is needed. We must emphasize that as medical care providers, our relationship is with you, not your insurance company. We provide the filing of your insurance claims as a courtesy; however, all charges are ultimately your responsibility. We realize that temporary financial problems may affect timely payment of your account. If problems do arise, please contact us for information on the management of your account. For those patients with no insurance or who choose to file their own, charges must be paid in full at the time of service. I have read and understand the above FINANCIAL POLICY. I understand that I am responsible for charges incurred as a result of the medical care provided to me by Knightsbridge Internal Medicine & Cardiology, Inc. Signature Date: 08/16

3 NEW PATIENT QUESTIONNAIRE PATIENT: ACCT #: DATE: What are your major problems today? REVIEW OF SYSTEMS: Please circle any symptoms Constitutional: Change in capabilities, general fatigue, fever, chills, weight change unexpected Endocrinology: Unusual or excessive thirst, appetite, urination, sweats or weight change Hematologic: Bruisability, bleeding, or lymph node enlargement Integument: Skin moles, rashes, or non-healing spots Psychiatric: Mood fluctuation, depression, stress, or memory loss Head/Eyes/Ears/Nose & Throat: Change in hearing, sight, taste, smell or voice Neurologic: Change in muscle strength, walking, coordination, falls, dizziness, seizures or strokes Respiratory: Cough, sputum, shortness of breath, wheezing, or infections Cardiovascular: Chest pain, pressure, aching, irregular heartbeat, flutters, racing, swelling, fluid retention, or leg cramps Gastrointestinal: Change in appetite, heartburn, gas, nausea, vomiting, change in stool color, or black tarry stool Genitourinary: Change in bladder function, frequency, burning, blood, or stones Gynecologic: (women) Discharges or pain Last Pap and pelvic Mammogram Musculoskeletal: Red, hot, tender joints, muscle aches or pains Prostate: (men) Trouble voiding or sexual dysfunction Last prostate exam Last PSA blood test

4 Patient Name: DATE: Past Medical History: Coronary artery disease Hypertension Cholesterol/Lipids Cancer Anemia Thyroid Bleeding Digestive Stroke Arthritic DATE Allergies: Hospitalizations: Date Operations: Date Vascular Procedures (catheterizations, coronary artery bypass graft, pacer, stent, etc) Eye exam Colonoscopy FEMALES Mammogram MALES Prostate exam or surgery Pap/Pelvic DEXA/Bone Density

5 PATIENT: DATE: SOCIAL HISTORY - << Please complete >> Married Work type Exercise program If yes, what? Alcohol If yes, how much? Tobacco If yes, how much & when started? Caffeine If yes, how much? Social Drugs Grapefruit juice If yes, how often? FAMILY HISTORY - << Please complete >> If yes, list who High blood pressure Heart disease _ Diabetes mellitus High cholesterol Cancer Strokes Any other diseases that run in your family line Brother Living Deceased Sister Living Deceased Mother Living Deceased Age Cause (if deceased) Father Living Deceased Age Cause (if deceased) Children (#) Any health problems? CURRENT MEDICATIONS Name Dose Frequency Doctor <<THANK YOU>> LRD NP