TURN OVER AND COMPLETE BACK OF FORM

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1 MRN: T C D PATIENT INFORMATION Today s Patient s Date: / / Name: (First) (MI) (Last) Address: City: State: Zip Code: Home #: ( ) - Alternate #: ( ) - Work #: ( ) - Soc Sec #: - - Gender: Male Female Marital Status: Married Single Divorced Widowed Legally Separated Race Language Ethnicity: Hispanic or Latin Not Hispanic or Latin Address: Referring Physician: Primary Care Physician: INSURANCE INFORMATION: PRIMARY INSURANCE: Company Policy Number: Group Number: Is the patient the policyholder? Yes No, if no, complete the following: Policyholder Information: Relationship: Male Female Phone Number: ( ) - SECONDARY INSURANCE: Company Policy Number: Group Number: Is the patient the policyholder? Yes No, if no, complete the following: Policyholder Information: Relationship: Male Female Phone Number: ( ) - PARTY RESPONSIBLE FOR PATIENT: Address: City: St: Zip: Relationship Male Female Soc Sec #: - - Home #: ( ) - Alternate #: ( ) - EMERGENCY CONTACT: Phone Number: ( ) - Address: Relationship: City: State: Zip Code: Male Female TURN OVER AND COMPLETE BACK OF FORM REVISED 3/29/2016 of Bay County:Download Forms:NEWPATIENT INFORMATION.doc Macintosh HD:Users:patrickholcombe:Documents: Plan-It Creative:Head & Neck Associates

2 PREFERRED PHARMACY: Please circle your preferred pharmacy and indicate the pharmacy location. Adams Pharmacy Bay Medical Center Cooper s Pharmacy CVS Kmart Mullins Pharmacy Publix Target Sam s Club St. Andrews Pharmacy Walgreens Wal-Mart Winn Dixie Other: Pharmacy Location: Be specific, Front Beach Road, Back Beach Road, Lynn Haven, 15 th Street, etc. AUTHORIZATION: I authorize Head and Neck Associates of Bay County, P.A. to release medical information or to give a copy of my medical records to the following people: 1) Phone Number: ( ) - 2) Phone Number: ( ) - Patient or Legal Guardian s Signature: Date: / / ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents. I hereby assign directly to Head and Neck Associates of Bay County, P.A. all benefits, if any, otherwise payable to me for services as described on the attached forms. I understand that I am financially responsible for any and all claim(s) not paid by my insurance company. Patient or Legal Guardian s signature: DATE: / / NOTICE OF PRIVACY PRACTICES My signature below indicates that I have been provided with a copy of the Notice of Privacy Practices. Patient or Legal Guardian s signature: DATE: / /

3 MRN: T C D MEDICAL HISTORY TODAY S PATIENT S DATE: / / NAME: (First) (MI) (Last) REFERRING PHYSICIAN: PRIMARY CARE PHYSICIAN: OCCUPATION: DOB: / / AGE: CHIEF COMPLAINT: HISTORY OF CHIEF COMPLAINT: (onset, duration, modifying factors) 1. **CURRENT MEDICATIONS**: Are you currently taking any medications, including aspirin, vitamins, and herbs? No Yes If yes, please complete the medication list form. Medication Name Milligrams Medication Name Milligrams 2. MEDICAL ILLNESSES: Circle all that apply Stroke Cancer Anemia Hiatal Hernia/ Acid Reflux Kidney Disease Seizure High Blood Pressure Bleeding Disorder Diabetes Arthritis Thyroid Disease Hyperthyroidism Hypothyroidism Goiter Heart Disease Asthma / Bronchitis Hepatitis AIDS/HIV *If Cancer circled, specify type: *Other Illnesses: 3. DRUG ALLERGIES: No Known Drug Allergies Yes, please list all drug allergies: TURN OVER AND COMPLETE BACK OF FORM * Information for Drs to enter, if needed ** Information for Medical Assistants to enter

4 MEDICAL HISTORY continued: 4. SURGICAL HISTORY: Circle all that apply Adenoidectomy / Tonsillectomy Septoplasty Tubes Ears Thyroidectomy / Parathyroidectomy Heart Surgery Hysterectomy Sinus Surgery Not Listed Neck Surgery Not Listed Cosmetic Surgery Healthy-No surgical history *OTHER SURGERIES: 5. FAMILY HISTORY: Circle all that apply M=Maternal (Mother or Mother s side of family) P=Paternal (Father or Father s side of family) CANCER DIABETES HEART DISEASE THYROID DISORDERS Maternal Paternal Maternal Paternal Maternal Paternal Maternal Paternal 6. SOCIAL HISTORY/HABITS: Alcohol Consumption: No Yes, how much? Smoke / Chew Tobacco: No Yes, how much? Age started? Age started? If no, is patient exposed to cigarette smoke? No Yes Do you have any inside dogs or cats? No Yes For patients less than 18 years of age, please answer the following: Does your child attend school? No Yes Does your child attend day care? No Yes Is your child up-to-date on vaccinations? No Yes 7. OTHER FAMILY MEMBERS: Are there other family members who are seen in this practice? No Yes, If yes, please print: * Information for Drs to enter, if needed ** Information for Medical Assistants to enter

5 HEAD AND NECK ASSOCIATES OF BAY COUNTY, P.A. 724 W. 19TH STREET, PANAMA CITY, FL PHONE (850) Quang T. Tran, M.D. Diana L. Barnett, ARNP-C Hans E. Caspary, M.D. Patient Name: Acct # Certain procedures performed in our office are not included in the standard office visit. These procedures will be billed separately and in addition to office visit charges. Some insurance carriers are classifying these procedures as "Surgery" and applying the charges to your surgical deductible, copayment, and/or co-insurance amount. This may result in insurance payment for an office visit but not the procedure. In such cases, payment for the procedure will be partially or completely patient responsibility. Examples of in-office procedures include: Fiberoptic laryngoscopy: This procedure involves passing a long fiberoptic scope either rigid or flexible instrument through the nasal cavity or into the throat. The fiber optic scope enables the physician to visualize areas of the throat not readily seen using the laryngeal mirrors or any other mean. Billing Code Charge Amount $165 Nasal endoscopy: This procedure uses the flexible or rigid scope attached to a light source to view areas of the nasal cavities that cannot be viewed by the physician using the standard nasal speculum or visual inspection. Billing Code Charge Amount $265 I have read the above information and understand my insurance company may reimburse an in-office procedure as a surgical service with the deductible and co-insurance guidelines applied. I also agree to the financial responsibility established by my insurance carrier according to my individual policy. If you have any question please feel free to speak with our staff and/or contact your insurance carrier for more information. Patient Signature Date Pediatric Otolaryngology Oncology Surgery Disorders of Larynx and Voice Laser Surgery Endoscopic Sinus Surgery Sleep Disorder Surgery Comprehensive Hearing Testing (Adult and Children) Vestibular Evaluation