Patient Name: Last name First Name Middle Initial. Address: Street or Box City State Zip Phone: (Primary) (Cell) (Other) Date of Birth:

Transcription

1 PATIENT REGISTRATION FORM Patient Name: Last name First Name Middle Initial Address: Street or Box City State Zip Phone: (Primary) (Cell) (Other) Date of Birth: Gender: o Male o Female SSN# Marital Status: o Single o Married o Widow/Widower o Divorced Employment Status: o Full Time o Part Time Employer: Student: o Full Time o Part Time School: Spouse Name: DOB: Emergency Contact: Relationship: Phone Number: Race: o American Indian or Alaskan Native o White o African-American o Hispanic o Asian o Native Hawaiian/Pacific Islander o Other: Ethnicity: o Hispanic o Non-Hispanic Preferred Language: How did you hear about us: o Newspaper o TV/Radio Ad o Yellow Pages o Internet/Web o Family/Friend o Other: Please complete is patient is a student or minor: Mother s Name: DOB: SSN# Address: Phone: Father s Name: DOB: SSN# Address: Phone:

2 AUDIOLOGY PATIENT HEALTH HISTORY In order for us to obtain a complete medical history, it is important for you to fill out this form as completely as possible. This is very important information. Please fill out every item. It is important for your doctor to know that you have carefully reviewed every area of this form. This information will be entered into the computer and you are welcome to a copy of the report if you wish. What is the reason you are seeing the doctor today? CURRENT MEDICATIONS: Are you taking ANY kind of medications now? (This includes prescription, over the counter or herbal medications) No Yes if yes, please list below and include dosages. Medication Name Dosage How often taken PAST HEALTH HISTORY Have you ever been DIAGNOSED with any of the following problems? Cancer (type) No Yes What Year Ears: Ear Infections No Yes What Year Hearing Loss No Yes What Year Past Hearing Aid No Yes What Year Meniere s disease No Yes What Year

3 Nose and Sinus: Chronic Sinusitis No Yes What Year Nasal Allergies No Yes What Year Nasal Polyps No Yes What Year Heart and Blood Vessels: High / Elevated Cholesterol No Yes What Year High blood pressure No Yes What Year Irregular Heartbeat No Yes What Year Allergies, Immune & Infection Problem: HIV No Yes What Year Infectious mononucleosis No Yes What Year Lupus No Yes What Year SURGIES AND HOSPITALIZATIONS: Have you ever had ear, nose, or throat surgery? No Yes If yes, list any surgeries and when they were done. Have you been hospitalized for non-surgical problem before? No Yes If yes, list hospitalizations, the reason for admission and the date. FAMILY HISTORY Ears: Hearing Loss before age 20 Mother Father Brother Sister Hearing Loss after age 20 Mother Father Brother Sister Nose and Sinus: Nasal Allergies Mother Father Brother Sister Nasal Polyps Mother Father Brother Sister

4 Heart and Blood Vessels: Heart Disease Mother Father Brother Sister Brain and Nervous: Stroke Mother Father Brother Sister REVIEW OF SYSTEMS: mark types or no and CHECK any of the following you have recently had. Ear problems No Yes ear pain ear drainage hearing loss Dizziness ringing Nose or Sinus problems No Yes chronic congestion, hay fever Post nasal drainage Brain or Nervous system problems No Yes numbness seizures Severe face pain weakness

5 Assignment of Benefits & Financial Agreement This assignment of Benefits allows Signature Hearing & Balance to be paid by my health insurance carrier or other health plan for the services provided to me, my minor child, or other person entitled to health care benefits on my plan. I understand that I am responsible to pay any services that are not covered by my insurance company. This includes but is not limited to, coinsurance, deductibles, non covered benefits due to policy limits or policy exclusions as well as failure to comply with my insurance plan requirements. If a referral and/or preauthorization is required by my insurance company, I will assist Signature Hearing & Balance in obtaining the referral and/or preauthorization. Any overpayment made by my insurance company (s) will be investigated and may be applied to any unpaid accounts for which I am listed as guarantor. Any refund will be made to the proper party, as stipulated in my insurance contract. I authorize the release of any medical information necessary to obtain payment of services and provide additional care. In the event that Signature Hearing & Balance has to engage an attorney or collection agency to collect any unpaid balances that arise from the treatment consented to herein, the undersigned agrees to pay the reasonable attorney s fees and collection expenses incurred by Signature Hearing & Balance. Consent for Treatment I hereby authorize Signature Hearing & Balance to examine, treat and perform diagnostic tests and office procedures that the physician deems necessary. I also authorize Signature Hearing & Balance to see all the medications prescribed by other physicians. HIPPAA Marketing Consent I authorize Signature Hearing & Balance to use, and/or disclose my protected health information to Signature Hearing & Balance which may be used to period ally send me information about health services offered within Signature Hearing & Balance. If you have consented to receive marketing information but no longer wish to receive further information please call to make your opt-out request. My Signature below indicated that I have read this consent form and fully agree to it. Scanned signatures suffice as original. I am 18 years old or older and authorize release of this information to YES NO (PLEASE CIRCLE) Name: Relationship