PATIENT INFORMATION FULL NAME First M.I. Last DATE OF BIRTH SOCIAL SECURITY # M / D / Y AGE: SEX: MALE or FEMALE STREET APT/SUITE #: CITY, STATE, ZIP City State Zip INSURANCE NAME POLICY/MEMBER ID: HOME PHONE # CONTACT INFORMATION MOBILE PHONE # EMAIL EMERGENCY CONTACT NAME PHONE #: RESPONSIBLE PARTY IF MINOR RELATIONSHIP: REFERRING DOCTORS REFERRING DOCTOR NAME PHONE # PRIMARY CARE DOCTOR PHONE # PHARMACY INFORMATION NAME PHONE # Page 1
Name Birth Date Today s Date Reason for visit MEDICAL HISTORY If you have any of the following medical problems with or without surgery please check and describe below: Abdominal Pain (L or R) Anemia Asthma Blood clots Cancer Diabetes Epilepsy/Seizures Fatty Liver / Cirrhosis Gallbladder GERD Gout Heart Disease Hernia High Blood Pressure HIV/ AIDS Hyperthyroidism Hypothyroidism Kidney Trouble Lung trouble/ Emphysema Sleep Apnea Stomach Ulcers Osteoarthritis Other:EXPLAIN ON PAGE 3 Allergies To: No Known Drug Allergies Penicillin Lidocaine Iodine Dye Sulfa Latex (rubber) Tape Other Allergies: _ Do you smoke? YES NO How often: How many years: Drink alcohol? YES NO How often: Have you ever had a colonoscopy? YES NO How long ago? Have you had your gallbladder removed? YES NO DIABETES FAMILY HISTORY INDICATE FAMILY MAJOR MEDICAL PROBLEMS & THEIR CURRENT STATUS: HYPERTENSION HEART DISEASE MENTAL ILLNESS CANCER STROKE DAUGHTER(S) FATHER SON(S) MOTHER PATERNAL G.FATHER PATERNAL G.MOTHER MATERNAL G.FATHER MATERNAL G.MOTHER Page 2
PATIENT NAME: MEDICATIONS - DOSAGE/HOW OFTEN OTHER MEDICAL PROBLEMS: PREVIOUS SURGERY WITH DATES: REVIEW OF CURRENT SYMPTOMS PLEASE CIRCLE ANY CURRENT SYMPTOMS YOU HAVE: GENERAL/CONSTITUTIONAL: Change in appetite Chills Fatigue Headache Night sweats Sleep disturbance Unexplained weight gain / loss ENT: Deviated septum Difficulty swallowing Mouth breathing at night Snoring ENDOCRINE: Cold / Heat intolerance Hair loss RESPIRATORY: Asthma Shortness of breath CARDIOVASCULAR: Chest pains/discomfort Dizziness Palpitations GASTROINTESTINAL: Abdominal pain Constipation Heartburn Nausea / vomiting HEMATOLOGY / BLOOD: Easy Bruising Prolonged bleeding Recent transfusion GENITOURINARY: Difficultly urinating Frequent urination Kidney problems MUSCULOSKELETAL: History of gout Muscle aches Painful joints NUEROLOGICAL: Headaches Memory Loss Fainting Sleep problems PSYCHIATRIC: Anxiety Depressed mood Eating disorder Page 3
FINANCIAL POLICY Our staff is concerned with the costs associated with your healthcare and wish to address current issues related to medical services provided in our office setting. Considerable care has been taken in the establishment of our fee schedule and we want to assure you our charges accurately reflect the complexity of care rendered along with the skill and expertise required in providing quality care to you. Items listed below are not covered by your insurance carrier and will be priced accordingly when the request is received by our office: All services will be filed with your insurance carrier with the exception of records request, FMLA or other associated paperwork, cancellation notices and returned check fees. Any medical service(s) not covered by your insurance plan will become your financial responsibility. Payment for services are due and payable with each visit. Deductible, co-payments, and co-insurance payments are due and payable at the time of service. If you are unable to provide payment of items deemed your financial responsibility, your appointment will be rescheduled for a later date and time. If you have an HMO plan, it is your responsibility to ensure you have the appropriate referral from your primary care physician. If you do not have the appropriate referral and our office must obtain one, a fee of $25.00 will be applied to your account. Returned checks will result in a $35.00 fee applied to your account. A 24 hour cancellation notice is required for office visits. If you are unable to make your scheduled appointment and do not provide a 24 hour notice to cancel, a $30.00 fee will be applied to your account. A request for medical records must be made in writing to our office. Upon receiving the request, our office will process the records request within a 72 hour period. The fee for Medical Records is $15.00 and is due and payable at the time of the request. Requests for the completion of the medical documents such as Disability leave, Cancer, Life or other health insurance forms, Employment exams, School physicals exams, Family Medical Leave (FMLA) or other documents required by a third party other than your insurance carrier will have a $15.00 fee per initial request ($10 each additional request) due at the time of request for said documents. Upon receiving the request our office will process the records request within a 72 hour period. ***We encourage you to contact your benefits coordinator through your employer or contact your insurance carrier directly to verify your own benefits, eligibility, and other services that may or may not be covered. Whether you have insurance coverage or not, the ultimate responsible party for services provided by our office staff and physicians will be you.*** I have read and understand my financial responsibilities as explained in this Financial Policy. Page 4
SURGERY CANCELLATION POLICY *THIS FORM APPLIES IF AND WHEN SURGERY IS SCHEDULED. YOU WILL NEED TO SIGN BEFORE YOUR FIRST APPOINTMENT* A time will be specifically reserved at the hospital for your scheduled surgical procedure. A cancellation policy is in place with regards to your surgical procedure which is designed out of respect for you, other patients and our surgeons. If you are unable to keep your surgical procedure at the specific date and time you have scheduled, a notice is required: $150 FEE - 1 week notice is required for general surgeries (Hernia repairs, gall bladder removals, endoscopy, etc.) $400 FEE - 2 week notice is required for all bariatric surgeries (Sleeve gastrectomy, bypass, duodenal switch, revisions) **This fee must be paid prior to re-scheduling your procedure for another day** By signing below, you acknowledge you have read and understand the cancellation policy for Beltline Bariatric and Surgical Group as described above, and have had the opportunity to ask questions pertaining to this cancellation policy. This policy may be subject to change. Page 5
SURGICAL ASSISTANT SERVICE PATIENT DISCLOSURE FORM *THIS FORM APPLIES IF AND WHEN SURGERY IS SCHEDULED YOU WILL NEED TO SIGN THIS BEFORE YOUR FIRST APPOINTMENT* Your surgeon will require the services of a Surgical Assistant for your upcoming surgical procedure (with the exception of Endoscopies). The fee for the Surgical Assistant IS NOT included in or a part of the Surgeon s fee or hospital charges. Your insurance may not cover the Surgical Assistant services or may consider the Surgical Assistant to be a non-participating, out of network, non-contracted or nonrecognized provider. The Surgical Assistant will file their claim separately from that of the surgeon and facility with your insurance. If your insurance denies benefits for services rendered by the Surgical Assistant you will be financially responsible. The Surgical Assistant will bill you directly if a balance is owed. Prior to disbursing payment for Surgical Assistant Services, your insurance may require documentation from your medical records in order to process claims and approve payments. By signing, you authorize any and all such releases of protected personal medical records. Medicare does not cover surgical assistant services. You will be billed separately for this fee. The fee ranges between $250 and $450 depending on the procedure. Page 6
AUTHORZATION FOR RELEASE OF MEDICAL RECORDS PATIENT NAME: DATE OF BIRTH: I authorize Beltline Bariatric and Surgical Group, LLC to use and disclose my medical records to the authorized physicians or individuals below under the following conditions: DISCLOSURE TERMS RELEASE DECLINE DATES OF SERVICE / / to / / AUTHORIZED PHYSICIANS NAME 1 PHONE # FAX # NAME 2 PHONE # FAX # AUTHORIZED FAMILY / FRIENDS / ETC. 1 2 NAME PHONE # RELATIONSHIP NAME PHONE # RELATIONSHIP I understand that I have a right to revoke this authorization at any time in writing. I understand that this authorization is voluntary, and that I do not need to sign this form in order to receive treatment. I understand that if the organization/persons authorized to receive the information is not a health plan or health care provider; the released information may no longer be protected by federal privacy regulations. Page 7
CONSENT TO OBTAIN EXTERNAL PRESCIPTION HISTORY As we strive to provide safe care, Beltline Bariatrics and Surgical Group requires consent to access your pharmacy records. I AUTHORIZE I DECLINE Beltline Bariatrics and Surgical Group to view my external prescription history via the RxHub service. I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and staff here. It may include prescriptions back in time for several years. MY SIGNATURE CERTIFIES THAT I READ AND UNDERSTOOD THE SCOPE OF MY CONSENT. RECEIPT OF NOTICE OF PRIVACY PRACTICES: *SEE ATTACHED PACKET* I ve been offered a copy of the Privacy Practices Policy of Beltline Bariatric and Surgical Group. I accept a copy of the policy I decline a copy of the policy Page 8