central oregon EAR NOSE THROAT

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Camron Hodge
5 years ago
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1 Medications: (list all your current medications and the dose) Allergies: (List medications/foods and what happens) Allergies to tape, iodine or latex: List the dates for the following radiology tests: Head X ray: Thyroid X ray: CT/MRI Scans: Upper GI/ Barium Swallow Today s Date: Name: Date of Birth: Seen at the request of: Dr./Nurse Practitioner: Clinic: Preferred Language: Race: q American Indian/Alaskan Native q Asian Ethnicity: q Hispanic or Latino q Native Hawaiian/Other Pacific Islander q White q Not Hispanic or Latino q Black/African American q Hispanic Chief Complaint / History of Illness: What is the reason for today s visit? How long have you had this problem? How severe is this problem? What makes it better? What makes it worse? What other symptoms are you having? My pain # is (0 to 10) No Hurt Hurts Hurts Hurts Hurts Hurts Worst Little Bit Little More Even More Whole Lot Are you being treated for High Blood Pressure? q Yes, Physician Name: q No Have you received the influenza (Flu) vaccine in the past 12 months? q Yes - Approximate Date: / / q No, declined previously. Allergy Testing: When? Clinic? Immunotherapy? Y N Social History: Occupation: Have you worked in a noisy environment? If so, what kind? Exposure to loud noises? Other: Do you smoke? Do you use chewing tobacco? How much? Are you thinking about quitting? When did you quit? How much alcohol do you drink each day? List any street drug use: Do you have an advanced directive? centmh 10/16

2 Past Medical History: Yes No High blood Pressure Kidney Disease Diabetes Thyroid Disease Tuberculosis/TB Rheumatic Fever Arthritis Please circle if applicable: Heart Disease / Angina / Asthma / Emphysema Stroke / Mini stroke / Liver Disease Hepatitis A B C / HIV / AIDS Cancer: (list type & date below) Others: Past Surgical History: Yes No Yes No Surgery for cancer Heart surgery Mastectomy Lung surgery Skin cancer surgery Colon Removal Sinus Surgery Neck/spine Tonsillectomy Others: Review of Systems: Yes No Yes No Ringing R Ear Hoarseness Ringing L Ear Throat Clearing Dizziness Swallowing pain Pain in R Ear Discomfort in throat Pain in L Ear Something in Throat Drainage from R Ear Cough Drainage from L Ear Heartburn/Sour taste Hearing loss R Ear Hearing loss L Ear White balls on tonsils Large tonsils Nasal congestion Nasal drainage Itchy nose/ears/eyes Facial pain Runny/watery eyes External facial deformity Sneezing fits Nasal bleeding (please circle) Right Left Runny nose Scratchy throat Loud snoring Stop breathing while asleep Excessive daytime sleepiness Skin cancers Blood in stool Vomiting Neck/back pain Nausea Loss of sensation Recent weight loss Paralysis of arm/leg Fevers/Chills Loss of speech Night sweats Facial droop Fatigue Chest pain/tightness Shortness of breath Poor circulation Wheezing Irregular heartbeat Others: Family History Yes No Yes No Hearing loss Stroke High blood pressure Diabetes Cancer Bleeding problems Alcoholism Heart Attack Psychiatric Illness Anesthesia Reaction Others:

3 ACKNOWLEDGEMENT AND CONSENT I understand that Central Oregon ENT, LLC (referred to below as This Practice ) will use and disclose health information about me. I understand that my health information may include information both created and received by This Practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. I understand and agree that This Practice may use and disclose my health information in order to: Make decisions about and plan for my care and treatment; Remind me of appointments; Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment; Determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and Perform various office, administrative and business functions that support my physician s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care. I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information. I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy of This Practice s Notice of Privacy Practices in effect will be posted in the waiting/reception area. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests. By signing below, I agree that I have reviewed and understand the information above, and that I may request a copy of the Notice of Privacy Practices from the front office. By: Date: Patient Signature -OR- By: Date: Patient Representative Signature Description of Representative s Authority: centa&c Rev 3/10

4 FINANCIAL POLICY Our Financial Policy is outlined below for your information. Please read it carefully. Our Business Office personnel are available to you; we encourage you to contact us with questions. We will do our best to clarify our policy and avoid misunderstandings. PAYMENT PAYMENT IS EXPECTED AT TIME OF SERVICE. We accept Cash, Checks, Visa & MasterCard. CO PAYS are due and payable prior to service. A $20 charge is assessed for Co-pays unpaid at time of service. DEPOSITS are due and collected before services on the following: o New Patient: (un-insured) $250 o Insurance Deductibles for HSA s: $250 o Cancellations with less than 24 hours notice: Payable before new appointment is made $ 50 o No-show: Payable before new appointment is made $ 50 o Cancelled Surgery: with less than 24 hours notice $250 o Office and Hospital Procedures not Covered by Insurance $ Cost of Procedure o Third Party Liability (i.e. Auto Accident & Personal Injury) $250 o BALANCES for Office Services are collected at check out o Surgery (for all non-emergent; non-life threatening cases) o Insured surgical services $ Unmet deductible/co-pay o Uninsured surgical services $ One half estimated charges Balance due upon receipt of statement Payment in full prior to services qualifies for TOS discount. DISCOUNT for PAYMENT IN FULL AT TIME OF SERVICE (TOS) 20% This discount is offered to our uninsured patients. To qualify, no subsequent insurance processing will be honored. Checks returned for any reason from the bank will lose this discount. PATIENT AND INSURANCE BALANCES are due upon of receipt of statement. CHILDREN & MINORS: The parent or legal guardian must be present for treatment, following state laws. The presenting parent/guardian is responsible for payment of services. Unaccompanied minors must show ability to pay for services with cash or supply contact with responsible parent/guardian, who must authorize charges and make any payments due at time of service. INSURANCE Proof of insurance is required; please bring your insurance information with you each time you visit our office. We participate with many major health plans and will bill your primary insurance as a courtesy. Presentation of proof of insurance does not exclude requirements of our payment policies listed above. Insurance coverage not presented at time of visit may not be honored. Please contact your health plan directly for confirmation of coverage, physician participation and covered benefits. It is your responsibility to obtain any referrals and/or prior authorizations required by your health plan. Many health plans require us to obtain a waiver or a Medicare Advanced Beneficiary Notice (ABN) before providing you services we expect might be denied for coverage. This waiver or ABN documents that you re aware coverage for services might be denied and you agree to be financially responsible for the charges. In these cases, refusal of signature will result in cancellation of your visit. MISC FEES In addition, the following fees are imposed in these financial instances RETURNED CHECKS o Checks returned from the bank for any reason $35 o TOS discount will be lost 20% o Co-pay returned are assessed an additional Unpaid Co-pay fee $20 REBILLING FEE o At time of processing of second and each subsequent billing cycle $ 5 COLLECTION ACTION o Accounts placed with a collection agency are assessed an Administrative Fee Approx $50-$100 PROCESSING FEES o Disability forms. Physicians Statements, FMLA Leave Requests $25

5 PATIENT INFORMATION FINANCIAL POLICIES 2450 NE Mary Rose Place, Ste 120 Bend, OR For further information please contact our Business (541) Payment for medical service is due at the time of visit unless prior arrangements have been made. I authorize Central Oregon ENT, LLC, dba Central Oregon Ear, Nose, & Throat to provide medical treatment for the person named below and agree to pay all fees and charges for such treatment. I authorize the release of information necessary to process the insurance claims and secure payment of benefits. I understand that as a courtesy my insurance claims will be submitted to my insurance carrier. I agree to pay all charges not covered by insurance or other contract medical programs within ninety days. I also agree that if it becomes necessary to place any past due amount with a collection agency, I am responsible for any related collection fees. We participate with many major health plans and will bill your primary insurance as a courtesy. Please contact your health plan directly for confirmation of coverage, physician participation and covered benefits. It is your responsibility to obtain any referrals and/or prior authorizations required by your health plan. I have read, understand and agree to the Financial Policies of CENTRAL OREGON ENT, LLC. Patient Name: DOB: Date: Signature: Responsible Party Print Name if other than Patient

MICHAEL E VILLANO, MD, FACS Board Certified, American Board of Otolaryngology, Head and Neck Surgery PATIENT INFORMATION

MICHAEL E VILLANO, MD, FACS Board Certified, American Board of Otolaryngology, Head and Neck Surgery PATIENT INFORMATION PATIENT INFORMATION Last name: First name: Middle initial: Date of Birth: Gender: Male Female Marital Status: M S W D Did another physician refer you to Dr. Villano? YES NO Referring Physician: Do you