NOWOBILSKA MEDICAL PRACTICE PATIENT REGISTRATION FORM 4201 West 95 th Street Oak Lawn, IL 60453

Transcription

1 NOWOBILSKA MEDICAL PRACTICE PATIENT REGISTRATION FORM 4201 West 95 th Street Oak Lawn, IL Please Print: Patient Name. First MI Last Address: City: State: Zip: Home Phone: Work Phone: Cell: Address: Sex: M F Martial Status: Single Divorced Married Widowed Social Security Number: / / Date of Birth: / / Patient s Employer: Address: City State: Zip: Person Responsible for Payment of Account: In Case of Emergency Call: Phone: Insurance: Please List the subscriber if other than the patient. Primary: Subscriber: Date of birth: Relation: I authorize the release of payment for medical benefits to my physician. Authorization to Release information: I hereby authorize Nowobilska Medical Practice to release any information acquired in the course of my examination or treatment to process insurance claims. I assign any benefits payable by my insurance carriers to my physicians. I understand that I am responsible for any amount not covered by my insurance carrier. Signature: Date:

2 Name D/O/B Date Please fill out completely, to the best of your ability YOUR FAMILY HEALTH ILLNESSES Name Birth Year Health is Died at if you or your family have had any of the Good Poor Age Cause of death following illnesses or problems Father YOU FAMILY Mother Alcoholism Brothers Anemia Asthma Cancer, Tumor Diabetes Drug Abuse Sisters Depression Eczema, Rash Epilepsy, Seizures Eye problems Spouse Glaucoma Children Heart Disease Kidney/Bladder Problems Liver disease, Hepatitis Lung disease, Tuberculosis Mumps, measles, chck pox Other Mental illness Phlebitis MEDICATIONS YOU ARE TAKING Rheumatic fever List medications, birth control, vitamins you take, prescription or non-pres. Rubella, German measles Stroke Suicide attempt Thyroid disease Ulcer in stomach Uncontrolled bleeding Venereal disease LIST ANY ALLERGIES YOU HAVE TO MEDICATIONS Other illnesses PREGNANCY HISTORY # of times pregnant # premature births # of miscarriages HOSPITALIZATIONS # of abortions List serious illnesses, injuries, operations that you have been hospitalized # of live births for and the approximate year. Please exclude normal pregnancies. # of living children IMMUNIZATIONS those you have had and when Flu shot Pneumonia Tetanus Form filed out by Patient Spouse Parent Other Signature

3 Nowobilska Medical Practice 5757 S. Cicero Ave W. 95 th St FINANCIAL POLICY Thank you for choosing Nowobilska Medical Practice as your healthcare provider. We are committed to providing the best medical care possible. Please understand that payment of your bill is considered a part of your treatment. The following statement explains our Financial Policy which we ask you to read, sign and return to us prior to treatment. All patients should provide accurate and complete personal including insurance information prior to being seen by our doctors. All applicable co-pays, personal balances, both current and prior, are due at the time of service. We accept cash and checks. Regarding Insurance We participate in most insurance plans. For some other insurance we accept assignment of benefits but in all cases we require that the guarantor, the person who is financially responsible, is personally liable for all balances not covered by insurance. It is your responsibility to understand and comply with any pre-determination of benefits or referral requirement. Please be aware that some, and perhaps all, of the services provided may be non-covered services or may not be considered medically necessary under the Medicare Program or by other medical insurance companies. Usual and Customary Rates We are committed to providing the best treatment for our patients and we charge what we believe to be reasonable and customary fees for region and specialty. If your insurance company uses a different fee schedule, you will be responsible for any balances remaining. Missed Appointments Unless canceled at least 24 hours in advance our policy to charge $25.00 for a missed appointment. Please help us serve you better by keeping scheduled appointments. This fee is not covered by insurance so it will be your personal responsibility. Past Due Accounts Overdue accounts will be referred to a collection agency. Legal fees that we pay to secure past due balances will be added to your account. Co-Pays Payments for co-pays are due at time of service. Returned Checks For checks returned to us as unpaid by your bank, we will charge a $30.00 fee. I have read and understand the Financial Policy. I agree to the Financial Policy. / / Print Name Signature Date

4 NOWOBILSKA MEDICAL PRACTICE Dr. Nowobilska, Dr. Szymanski Thinking about you and your health we as your doctors would like to present you the most recent recommendations regarding screening exams according to age and sex group. Please read it and make sure that you are not late for these important and recommended tests and procedures. If you do not do these tests or have any questions about them we will be happy to help you during your next office visit Age Test Name Males Females Reason >18 Tetanus Booster Every 10 Years Every 10 Years Tetanus Prevention >18 Blood Pressure Every Visit Every Visit Hypertension >21 Pap Smear N/A Every 1-2 Years Cervical Cancer >35 Cholesterol Yearly Yearly Heart Problems 40 Mammogram N/A Yearly Breast Cancer >50 Prostate (PSA) Yearly N/A Prostate Cancer 50 Colonoscopy Every 6-10 Years Every 6-10 Years Colon Cancer >50 Flu Vaccine Yearly Yearly Flu Prevention >65 Pneumonia Vacc. Once Once Pneumonia Prevention >65 TSH Once Once Hypothyroidism >65 Dexa Scan Once Once Osteoporosis I reviewed all above recommendations. Patient Name: Signature: Date:

5 Nowobilska Medical Practice 5257 South Cicero Ave., Chicago, IL West 95 th Street, Oak Lawn, IL AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO INDIVIDUALS/FAMILY MEMBERS In accordance with Federal government privacy rules implemented through Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), in order for your physician and/or staff of our practice to discuss your condition with members of your family or other individuals that you designate, we must obtain your prior authorization prior to do so. In the event of a critical episode or if you are unable to give your authorization do to severity of your medical condition the law stipulates that these rules may be waived. PLEASE MARK ONE I do not authorize the practice to release any or all information concerning my medical care to any individual except as set forth above. I authorize the practice to verbally release any or all information concerning my medical care to the following materials. Name Relationship to Patient Name Relationship to Patient Signature Date Witness Date COMMENTS:

6 Nowobilska Medical Practice 5257 S. Cicero Ave., Chicago, IL West 95 th Street, Oak Lawn, IL Tel: (773) Fax: (773) NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT I understand that, under the Health Insurance Portability & Accountability Act of 1996 ( HIPAA ), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you agree than you are bound to abide by such restrictions. PATIENT NAME: _DATE: RELATIONSHIP TO PATIENT: SIGNATURE: Office Use Only I attempted to obtain the patient s signature in acknowledgment on this Notice of Privacy Practices Acknowledgment, but was unable to do so as documented below: DATE: INITIALS: REASON: