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

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Sharleen Singleton
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1 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 MD Primary Care MD Same Pharmacy Preference Name: Name: Name: Phne: Phne: Phne: Address: Address: Address: Operatins Allergies Reasn fr Visit: Height: Weight: D yu drink alchl? N, never N, but used t Yes Hw many drinks? day/week D yu smke? N, never N, quit Yes Packs per day x years Illicit drug use? N, never N, but used t Yes Which drug? D yu currently have any f the fllwing prblems? Cnstitutinal Respiratry Skin Weight gain/lss Y N Shrtness f breath Y N Rash Y N Fevers Y N Cugh Y N Mles Y N Ears/Nse/Thrat Gastrintestinal Neurlgic Hearing Lss Y N Diarrhea Y N Headaches Y N Ear Pain Y N Cnstipatin Y N Leg/arm weakness Y N Nasal cngestin Y N Heartburn Y N Endcrine Runny nse Y N Musculskeletal Thyrid disease Y N Facial pain/pressure Y N Arthritis Y N Diabetes Y N Cardivascular Chrnic back pain Y N Hematlgy High bld pressure Y N Geniturinary Easy bruising Y N Heart murmur Y N Frequent urinatin Y N Anemia Y N Urinary incntinence Y N Psychiatric Immunlgic/Allergy Anxiety Y N Seasn allergies Y N Depressin Y N Reviewed By: REV. 03/26/2016

2 PATIENT FORM Name: Sex: M F DOB: Address: City, State: Zip Cde: Hme Phne: Cell Phne: Address: Mther s Name (PEDS PT): Father s Name (PEDS PT): Mther s DOB: Father s DOB: Emplyer Name: Emplyer Address: City, State: Zip Cde: Emergency Cntact: Hme Phne: Relatinship: Wrk Phne: INSURANCE INFORMATION Primary Insurance Name: Certificate/Plicy# Grup#: Phne Number: Insured s Name: Relatin t insured: Insured s DOB: Effective Date: Expiratin Date: SECONDARY Insurance Name: Certificate/Plicy# Grup#: Phne Number: Insured s Name: Relatin t insured: Insured s DOB: Effective Date: Expiratin Date: REV. 03/26/2016

Department f Otlarynglgy 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:

3 Department f Otlarynglgy 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 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

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

4 Department f Otlarynglgy 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

5 Department f Otlarynglgy 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 MEDICAL QUESTIONAIRE

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