Texas Rheumatology Care

Transcription

1 PATIENT INFORMATION (Please print patient information below.) Page 1 of 12 Patient s Name (First, MI, Last) Date Of Birth Patient s Address (Number, Street., Apt.) Home Phone (include area code) City State Zip Age Sex Marital Status Social Security # Driver s License # Employer Referring Doctor PRIMARY INSURANCE INFORMATION (Please print policyholder information below.) Policyholder s Name (First, MI, Last) Date Of Birth Policyholder s Address (if same a patient s address, write same ) Home Phone (include area code) City State Zip Work Phone (include area code) Employer Social Security # of Policyholder Relationship to the patient Spouse _Parent _Other Referring Physician Information Physician Name Practice Name Phone # Today s Date Signature (Patient or parent if under 18 years of age)

2 EMERGENCY CONTACT INFORMATION Please list someone we could contact in case of an emergency. Page 2 of 12 Name Phone # (include area code) Address Relationship City State Zip INSURANCE BILLING AND PAYMENT INFORMATION IN ORDER TO CONTROL YOUR COST OF BILLINGS, WE REQUEST THAT CHARGES FOR OFFICE VISITS BE PAID AT THE CONCLUSION OF EACH VISIT. Please remember that Insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for the payment. Some companies pay fixed allowances for the certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible, co-insurance, or any other balance not paid for by your insurance. If this account is assigned to an attorney for collection and/or suit, the practice shall be entitled to reasonable attorney's fees and costs of collection. I authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits to which I am entitled including medicare, private insurance and other health plans payable to the practice named on the top of this form. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. Today s Date Signature (Patient or parent if under 18 years of age)

3 NOTICE OF PRIVACY PRACTICES - EFFECTIVE APRIL 14, 2003 This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. We understand that medical information about you is personal and we are committed to protecting it. Texas Rheumatology Care is required by law to maintain the privacy of your health information, to follow the terms of this notice, and to provide you with this Notice of our legal duties and privacy practices with respect to your health information. We may use or disclose your information: For treatment purposes For payment purposes For Health Care Operations For Appointment Reminders and Health-Related Products and Services To Individuals involved in your Care or Payment for Your Care. We may also disclose your health information: As Required by Law. To Avert a Serious Threat to Health or Safety For Public Health Activities/Risk Prevention For Health Oversight Activities For Lawsuits and Disputes For Specialized Government Functions For Worker's Compensation or other similar programs Except as described in this Notice, Texas Rheumatology Care will not use or disclose your health information without your written authorization. If you do authorize Texas Rheumatology Care to disclose your health information, you may revoke your authorization in writing at any time. You have the Following Rights with Respect to your Health Information: You have the right to request that we follow special restrictions when using or disclosing your health information for treatment, payment or health care operations, or to someone who is involved in your care or the payment for your care. With certain exceptions, you have the right to inspect and copy your health information. You have the right to request that we amend your health information if you feel that it is incorrect or incomplete. You have a right to request an accounting of disclosures of your health information. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. Texas Rheumatology Care Reserves the right to change this Notice. If we change our Notice, you may obtain a copy of the revised Notice by request. To file a complaint, please contact: HIPPA Coordinator, 6300 Stonewood Dr. #412, Plano, TX By signing below, I acknowledge that I have received Texas Rheumatology Care's Privacy Notice: Page 3 of 12 Today s Date Signature (Patient or parent if under 18 years of age)

4 BONE DENSITY PATIENT QUESTIONNAIRE Page 4 of 12 Name (Please Print) Date Is there a chance you might be pregnant? Yes No Have you had a barium X-ray in the last few weeks? Yes No Have you had a nuclear medicine scan or injection of an X-ray dye in the last weeks? Yes No If you answered YES to an to any of the above, speak to our receptionist before continuing. Do you have any metal in spine and/or hips? Yes No Have you ever broken or fractured a hip? Yes No Do you have times when you fall for no specific reason? Yes No Have you ever been told that you have osteopenia or osteoporosis (significant bone loss)? Yes No Do you take medicine for osteopenia or osteoporosis? Yes No Do you a family history of osteoporosis? Yes No Have you lost height (become shorter)? Yes No Have you had a recent weight change? Yes No Do you take calcium pills? Yes No Do you take Vitamin D or Multi-Vitamins? Yes No Do you take medicine to control seizures, epilepsy, or convulsions? Yes No Do you take steroids for chronic arthritis and/or asthma? Yes No Do you take medicine for thyroid problems? Yes No Do you have any kind of intestinal problem such as Crohn s Disease or Ulcerative Colitis? Yes No Have you had renal (kidney) failure? Yes No If so, are you on dialysis? Yes No Do you consume beverages with alcohol? Yes No If so, how many per day? Do you consume smoke cigarettes? Yes No If so, how many per day? Do you take birth control or any type of estrogen? Yes No Have you had a hysterectomy? Yes No Are you in menopause? Yes No Are you on hormone replacement therapy? Yes No Patient Signature

5 Page 5 of 12 AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (Paper, Oral & Electronic) Patient s Name Social Security # Address ( Street, Apt. #, City, State, Zip) Date Of Birth Information Release Request Date THE PURPOSE OF THIS AUTHORIZATION IS: Investigation/Assessment/Case Planning Creating Health Information For Disclosure To A Third Party Further Medical Care Changing Physicians Other_ RECORDS REQUESTED: Entire Record Lab/X-RAY Reports, MR/DD Records Medical History/Exam Reports Treatments and Tests Hospital Records From: / / to / / Surgical Reports Other By signing this document I (the above patient) authorize Dr. Address Phone: Fax: To release the above information to: Dr. Fehmida Zahabi Texas Rheumatology Care 6300 Stonewood Drive, Suite 412, Plano, TX Phone: , Fax: This authorization expires on. If I do not specify an expiration date, this authorization expires six months from the signature date. Today s Date Authorized Signature (Patient or parent if under 18 years of age)

6 OFFICE INFORMATION Page 6 of 12 Thank you for choosing our office. The following information may help answer some questions you may have after your first visit and future visits. You will receive notification of all test results within 10 days of the test. If after 10 days you have not heard from us by phone or letter, please contact us at that time. Our office telephone number is Our staff answers the phone Monday thru Thursday, from 8:30 a.m. to 5:30 p.m. We ask that all non-emergency calls be made during this time period. Please remember that our phone is not answered after hours or on Friday, Saturday or Sunday. If you have a situation and need to contact our office during non-office hours, please call and leave a message when prompted. Your call will be returned the following business day. Patients with medical emergency should go directly to the nearest hospital or emergency care facility. The ER doctor can contact the on-call physician. For all non rheumatologic emergencies, please contact your individual primary care physician. If you do not have one please contact your nearest urgent care facility. For medical records and forms completion, their will be a $25 charge. Please allow 2 weeks for processing. PRESCRIPTION REFILLS If you need a prescription refilled, please contact the pharmacy that dispensed the medication. Even if the pharmacy indicated that no refills are remaining, in most cases we will fill the prescription after the pharmacy contacts our office. To ensure that you do not go without medication, please contact your pharmacy for refills at least 48 hours before you will need your medication. For all hand written prescriptions please allow 48 hours before the medication is needed. HOSPITALIZATION There may be times when your medical condition requires hospitalization. Although Dr. Zahabi has consultation privileges at Richardson Regional Hospital and Medical City Dallas, she does not admit to the hospital. If necessary she will refer you to your primary care physician or hospitalist who will care for you while you are hospitalized. During your hospital stay your primary hospitalist will update Dr. Zahabi about your condition or, at your doctor's request; Dr.Zahabi will be an active participant in your care while you are hospitalized. APPOINTMENT CANCELLATION Please give a 24 hours notice for all appointment cancellations, without a cancellation call you are subject to a $40 charge that your insurance will not cover. Today s Date Authorized Signature (Patient or parent if under 18 years of age)

7 Page 7 of 12 PATIENT HISTORY Date of First Appt. (Month/Day/Year) Time of Appt. Birthplace Birth Date (Month/Day/Year) Name (Last, First, Middle Initial) Maiden Name Address (Street, Apt. #, City, State, Zip) Age Sex Phone # Work Phone # Home Phone # Cell Martial Status: Never Married Married Divorced Separated Widowed Spouse/Significant Other: Alive - Age Deceased - Age Major Illness Education: (Circle highest level attended) Grade School: College: Grad School Occupation Number of Hours Worked Per Week (average) Referred Here By: Self Family Friend Doctor Other Health Professional Name of Person Making Referral Your Primary Care Physician & Phone Number Describe briefly your present symptoms Date symptoms began (approx.) Previous diagnosis from other physicians (include physical therapy, surgery, injections; meds to to listed later). MEDS LISTED LATER List the names of other practitioners you have seen for this problem. Rheumatologic (Arthritis) History ( If at any time you or a blood relative has had any of the following, indicate below) Yourself Relative/Relationship Yourself Relative/Relationship Arthritis (Unknown Type) Lupus or SLE Osteoarthritis Rheumatoid Arthritis Gout Ankylosing Spondylitis Childhood Arthritis Osteoporosis Other arthritis conditions: Today s Date Authorized Signature (Patient or parent if under 18 years of age) Physicians Initials

8 Name SYSTEM REVIEW Page 8 of 12 Today s Date Authorized Signature (Patient or parent if under 18 years of age) Physicians Initials

9 Name ACTIVITIES OF DAILY LIVING Page 9 of 12 Today s Date Authorized Signature (Patient or parent if under 18 years of age) Physicians Initials

10 Name PATIENT HISTORY Page 10 of 12 Today s Date Authorized Signature (Patient or parent if under 18 years of age) Physicians Initials

11 Name MEDICATIONS Page 11 of 12 Name Today s Date Authorized Signature (Patient or parent if under 18 years of age) Physicians Initials

12 Name MEDICATIONS (CONT.) Page 12 of 12 Today s Date Authorized Signature (Patient or parent if under 18 years of age) Physicians Initials