PATIENT MEDICAL QUESTIONAIRE

Size: px

Start display at page:

Download "PATIENT MEDICAL QUESTIONAIRE"

Arleen Gregory
6 years ago
Views:

1 PATIENT FORM William I. Kuhel, MD PATIENT MEDICAL QUESTIONAIRE Name: Ht: Wt: Date: Occupatin: 1. Majr Cmplaint (describe in yur wn wrds why yu are cming in t the see the dctr) 2. Referred by: Name and Address f yur primary care physician (mit address if physician is n staff at NewYrk-Presbyterian Hspital): 3. List name and address f any physician wh shuld receive a summary letter regarding yur evaluatin (use extra sheet if necessary) 4. List all current medical cnditins (diabetes, high bld pressure, heart disease, gut, tuberculsis, etc) 5. List all surgeries and the years that they ccurred: 6. List all medicatins that yu are taking (including eye drps, aspirin, mtrin, nasal sprays, vitamins, etc.) 7. List all drug allergies: Drug: Type f reactin: Drug: Type f reactin: Drug: Type f reactin: 8. Smking Histry D yu smke? Yes, I ve smked Packs per day fr years Yes, I smke cigars r a pipe N, I never smked N, I quit years ag. Prir t that I was smking packs per day fr years WILLIAM I. KUHEL, MD WEILL CORNELL MEDICAL COLLEGE REV. 03/24/2016 1

2 PATIENT FORM William I. Kuhel, MD 9. Alchl Histry D yu drink alchlic beverages regularly? Yes N If n, did yu drink regularly in the past? Yes N If Yes, year that yu quit Try t quantify expsure t alchl: Drinks per day fr; years; less than ne alchlic beverage per day But mre than ne per week ; Less than ne alchlic drink per week 10. D yu have any f the fllwing symptms? (Please d nt leave any blanks): Cnstitutinal Fevers Yes N Chills Yes N Sweats Yes N Weight Lss/Gain Yes N Gastrintestinal Indigestin r pain with meals Yes N Heartburn Yes N Skin Histry f Skin Cancer Yes N Radiatin t the head/neck regin Yes N Reviwed By: William I. Kuhel MD Date WILLIAM I. KUHEL, MD WEILL CORNELL MEDICAL COLLEGE REV. 03/24/2016 2

Department f Otlarynglgy Head and Neck Surgery Telephne: 646 962 5300 Weill Crnell Medical Cllege Fax: 646 962 0030 1305 Yrk Avenue, 5 th Flr New Yrk, NY 10021 CONSENT FOR RELEASE OF MEDICAL

3 Department f Otlarynglgy Head and Neck Surgery Telephne: Weill Crnell Medical Cllege Fax: Yrk Avenue, 5 th Flr New Yrk, NY CONSENT FOR RELEASE OF MEDICAL INFORMATION NO PHYSICIAN OR INSTITUTION MAY GIVE CONFIDENTIAL INFORMTION WITHOUT THE CONSENT OF THE PATIENT. IF THE PATIENT IS A MINOR, THE CONSENT MUST BE SIGNED BY THE PARENT OR LEGAL GUARDIAN AND SHOULD BE WITNESSED KINDLY FURNISH TO: DR. WILLIAM I. KUHEL AT WEILL CORNELL MEDICAL COLLEGE DEPARTMENT OF OTOLARYNGOLOGY HEAD AND NECK SURGERY 1305 YORK AVENUE, 5 TH FLOOR, NEW YORK, NY THE FOLLOWING INFORMATION FROM MY MEDICAL RECORD: Patient Name: DOB: Address: Signature: Date: Relatinship t Patient if nt Patient: Witness: VIA FAX (number listed abve) WILLIAM I. KUHEL, MD WEILL CORNELL MEDICAL COLLEGE REV. 03/24/2016

4 Department f Otlarynglgy Head and Neck Surgery REFERRING PHYSICIAN, MEDICATION AND PHARMACY INFORMATION FORM Patient s Name: Name and Address f Internist r Referring Dctr: Physician s Name: Address: Date: Telephne: Fax: MEDICATIONS D yu have any allergies t medicatins? N Yes (Please List): Please list all medicatins that yu are taking (including ver-the-cunter medicatin, such as eye drps, aspirin, Mtrin, nasal sprays, vitamins, herbal remedies, birth cntrl pill, etc.) MEDICATIONS DOSAGE (mg, teaspn, etc) FREQUENCY VACCINATION HISTORY Date f mst recent Flu Sht (ages 6 ms +) Date f mst recent Pneumnia Sht (ages 65+) PHARMACY INFORMATION In rder t expedite prescriptin service, if required, we wuld like t have yur pharmacy infrmatin n file Pharmacy Name: Address Telephne: Fax: Patient s Signature: OTOLARYNGOLOGY WEILL CORNELL MEDICAL COLLEGE REV. 03/24/2016

Department f Otlarynglgy Head and Neck Surgery OTOLARYNGOLOGY (ENT) PAYMENT POLICY FOR IN-OFFICE PROCEDURES In additin t an ffice visit, cnsultatin and examinatin, yur care may als invlve ffice

As per custmary practice with medical insurance carriers, these ffice prcedures are billed as a distinct prcedure frm the ffice visit.

5 Department f Otlarynglgy Head and Neck Surgery OTOLARYNGOLOGY (ENT) PAYMENT POLICY FOR IN-OFFICE PROCEDURES In additin t an ffice visit, cnsultatin and examinatin, yur care may als invlve ffice prcedures that are rutinely perfrmed in the evaluatin and treatment f Ear, Nse and Thrat cnditins. As per custmary practice with medical insurance carriers, these ffice prcedures are billed as a distinct prcedure frm the ffice visit. Yur health plan may categrize these prcedures as surgical and apply the fees fr these services t yu as a cpay, c-insurance, deductible and/r ut-f-pcket charge. This is based n yur cntract with yur insurance carrier. These prcedures include, but are nt limited t, the fllwing: Nasal Endscpy: Examinatin f the nasal and paranasal sinus cavities with a fiberptic endscpe. Nasal Endscpy with debridement r bipsy: Includes a nasal endscpy and additinally includes remval f crusting r tissue. Flexible Laryngscpy: Examinatin f the thrat with a fiberptic endscpe. Laryngeal Strbscpy: Examinatin f the larynx and vcal crds under strbscpic light. Cerumen remval: Remval f wax frm the ear canals. By signing this frm, yu acknwledge that yu are aware f this plicy and understand that yu are respnsible fr any f the assciated fees. Patient Name: (Print) Signature: (Patient r Respnsible Party) Date: REV.03/24/2016

6 Department f Otlarynglgy Head and Neck Surgery Financial Plicy Welcme t the Department f Otlarynglgy-Head & Neck Surgery. The fllwing is a statement f ur financial plicy. We hpe this gives yu a better understanding f hw ur billing wrks. Financial Plicy Patients have many different types f insurance and payment ptins fr services rendered. Als, nt all physicians in the practice accept the same type f insurance. The three mst cmmn scenaris are utlined belw. Please read the fllwing and if yu have any questin r cncerns please call the ffice f the physician yu are seeing. Participating Plans In this scenari the physician yu will see participates with yur insurance plan. It is yur respnsibility t ensure yur physician is in fact currently a prvider in that plan. At the time f service yu will be respnsible fr all c-payments and cinsurances as utlined by yur plan cverage. We will cllect yur c-insurances and deductibles in advance if yu are having a prcedure in the ffice r hspital. The Medical Cllege will then frward a bill t yur insurance carrier wh will cnfirm if any additinal payments are due frm yu. Yu will receive written ntificatin f such decisin and may ultimately be respnsible fr such payments as determined by yur insurance cmpany. If yur plan requires a referral, please present the referral at the time yu check-in. If yu d nt have a referral yu may have t reschedule yur appintment. Nn-Participating Plans In this scenari the physician yu will see des nt participate in yur insurance plan. Payment f services is due at the time f the visit. We can submit the claim directly t yur carrier r a claim can be mailed directly t yu. Medicare Fr any f ur prviders that participate with Medicare, we will bill Medicare directly fr yur service and Medicare will send payment directly t the physician. Yu will be respnsible fr any deductible r c-insurance. If yur physician des nt participate with Medicare yu will be respnsible fr payment at the time f service, and yur claim will then be frwarded t Medicare and they will reimburse yu directly. Usual and Custmary Rates Yur insurance plicy is a cntract between yu and yur insurance cmpany. Our practice is cmmitted t prviding the best treatment fr ur patients and we charge what is usual and custmary fr ur area. Yu are respnsible fr payment regardless f any insurance cmpany s arbitrary determinatin f usual and custmary rates. Payment Cash, Check, MasterCard, Visa, Discver and American Express card are recgnized frms f payment. We hpe this infrmatin is helpful; Again, if yu have any questins r cncerns, please cntact yur physician s ffice. Signature f Patient r Respnsible Party Date REV. 07/06/2016

PATIENT FORM. Abtin Tabaee, MD. Reviewed By: Referring MD Primary Care MD Same Pharmacy Preference Name: Name: Name: Phone: Phone: Phone:

PATIENT FORM. Abtin Tabaee, MD. Reviewed By: Referring MD Primary Care MD Same Pharmacy Preference Name: Name: Name: Phone: Phone: Phone: PATIENT FORM Patient Name: Date f Birth: High bld pressure Diabetes Heart disease Strke Asthma Other: Past Medical Histry COPD Thyrid disease Seizures Anxiety Depressin Medicatins (Name, dsage) Referring