Please complete the following forms to help expedite your visit! Preferred pharmacy location: Patient Medical History Form Patient's Name: DOB: Referring Doctor: What are your concerns for today's visit? Past Medical history: Past illness: 1) 2) 3) 4) 5) Medications: 1) 3) 2) 4) Allergies to medications: Medicine 1: Medicine 2: Side effect: Side effect: San Antonio, Texas 78248 1
Past surgeries: Please check the "Yes" or "No" box to indicate if your child has had the following illness: Ear Infection: O Yes O No If yes, please answer the questions below: How many ear infections in the past 12 months? Was there any drainage with the ear infection? O Yes O No Are both ears draining or just one? O Both O Just one Are there fevers associated with the ear infections? O Yes O No Have there been other hearing problems with the infections? O Yes O No Which antibiotic has your child taken for ear infections in the past 12 months? Nose or Sinus problems: O Yes O No If yes, please describe the sinus problems: Throat infection: O Yes O No If yes, please answer the questions below: How many throat infections in the past 12 months? How many of these infections were strep positive? Which antibiotic has your child taken for the throat infections? Frequent snoring: O Yes O No If yes, please answer the questions below: Is there tossing and turning during sleep? O Yes O No Does your child have pauses "apnea" during the snoring? O Yes O No If yes, how long do the pauses last? Does your child turn blue during the snoring? O Yes O No San Antonio, Texas 78248 2
Allergy Problems: O Yes O No If yes, please answer the questions below: Does your child have frequent sneezing, itchy and watery eyes? O Yes O No If yes, what allergy medications has your child been on in the past 12 months? Does your child have an allergist? O Yes O No If yes, Name: Is your child currently on imuno therapy? O Yes O No Airway Problems (excluding snoring): O Yes O No If yes, please describe the airway problem: Is there noise during the airway problem? O Yes O No Does the noise occur when your child breathes in our out? O Breathes in Does your child turn blue during the airway problem? O Yes O No O Breathes out O Both I have reviewed the above information. Juan A. Bonilla, M.D. R.Donald Moe, M.D. San Antonio, Texas 78248 3
Financial Policy Thank you for choosing, P.A. as your health care provider; we are committed to providing your child with the best available medical care. Our billing department will be available to discuss our fees and this policy with you if you have any questions. We ask that all responsible parties read and sign our financial policy as well as complete the patient information form prior to seeing the physician. Payments for services are due at the time services are rendered. We accept cash, check, Visa, MasterCard and Discover. We will be happy to help you file your insurance claim for reimbursement. In special instances we may not accept assignment for benefits. However you must understand the following Initials Required 1) Your insurance policy is a contract between you, your employer and the insurance company we are NOT a party to that contract. Our relationship is with you, not your insurance company. We cannot become involved in disputes between you and your "usual and customary" charges. Our involvement will be limited to supplying factual information to facilitate claim processing. 2) All charges are your responsibility whether your insurance company pays or does not pay. Not all services are covered benefits in your medical plan. Some insurance companies arbitrarily select certain services they will not cover. i.e. audiology testing or cosmetic testing. 3)Fees for services, along with unpaid deductibles and co-payments are due at the time of service. 4) If your insurance company does not pay the claim within 45 days, it is your responsibility to contact your insurer to expedite payment. However, if your insurance should pay your claim and you are due a refund, under normal circumstances processing the refund may take up to but not exceed six weeks. All refunds are issued via check. If our office however finds that you have an outstanding balance, our office will apply your credit to that balance, the difference if any will then be refunded to the patient. San Antonio, Texas 78248 4
5) Returned check and unpaid balances may be subject to collection placement, and collection fees. The returned check fee is $25.00 6) I have agreed to pay, in a current manner, any balance of said professional charges over and above this insurance payment. 7) All Medicaid patients will be private pay if there is no authorization on file. We understand that temporary financial problems may affect timely payments of your balance. We encourage you to communicate any such problems to us, so that we may assist you to keep your account in good standing. Again thank you for choosing Pediatric, Ear, Nose and Throat Institute of South Texas, P.A. as your health care provider. We appreciate your trust in us and we appreciate the opportunity to serve you. Signature: Date: San Antonio, Texas 78248 5
Demographics and Insurance Information (IN ORDER TO COMPLY WITH HIPAA REGULATIONS, ALL INFORMATION MUST BE FILLED OUT COMPLETELY) Patient Information Patient's Name: Date of Birth Social Security #: Sex O male Street Address City & State Zip Code Home Phone O female Parent's Name Street Address, City,State, Zip Code Cell Phone Parent's Employer Occupation Social Security # Date of Birth Employer's Street Address City & State Zip Code Work Phone Parent's Name Street Address, City,State, Zip Code Cell Phone Parent's Employer Occupation Social Security # Date of Birth Employer's Street Address City & State Zip Code Work Phone Emergency Contact (other than parent) Relationship to Patient Home Phone Parents Marital Status O Single O Married O Separated O Divorced O Other Insurance Information Primary Insurance Street Address, City, State, Zip Code Insurance Phone Name of Insured/ Guarantor Policy Number Group Number Is the child covered under another medical plan? O Yes O No Secondary Insurance Street Address, City, State, Zip Code Insurance Phone Name of Insured/ Guarantor Policy Number Group Number Medicaid Number CIDC Number Name on Card Account # Physician Information Pediatrician/Family Doctor Street Address, City, State, Zip Code Phone # Fax # Responsible Party Signature San Antonio, Texas 78248 6 Date
Consent to Treatment I am the Parent Legal Guardian Other (please specify) of I authorize the following Person(s) list relationship To Make Medical/ Surgical decisions (when necessary) I hereby give consent to X Dr. Juan A Bonilla X Dr. R. Donald Moe X Scott Duhaime, MPAS PA-C To examine and administer any necessary medical care for my child. Patient name Signature Date San Antonio, Texas 78248 7
PEDIATRIC EAR, NOSE AND THROAT INSTITUTE OF SOUTH TEXAS ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I,, have received a copy of the office's notice of Privacy Practice. Patient Name Date of Birth Date Parents Signature Please Print Name For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: O Individual refused to sign O Communication barriers prohibited obtaining the acknowledgement O An emergency situation prevented us from obtaining acknowledgement O Other (please specify) San Antonio, Texas 78248 8
CONSENT FOR ELECTRONIC MAIL (EMAIL) USE I, am the legal representative of an established patient (please print patient name). I may want to communicate with Providers and staff by use of email. I understand the risks of communicating be email, in particular the privacy risks.i understand that PENT cannot guarantee the security and confidentiality of e-mail communication. PENT will not be responsible for messages that are not received or delivered due to technical failure, or for disclosure of confidential information unless caused by intentional misconduct. I understand that I may revoke this consent at any time by advising PENT in writing of my decision. My revocation of consent will not affect my ability to obtain future health care nor will it cause the loss of any benefit to which I am otherwise entitled. I have read and understand this form. I have had the opportunity to ask questions and have had them answered to my satisfaction. I understand and agree with the information contained in this form and give my consent for email communications to and from PENT. PATIENT AUTHORIZATION/EMAIL: Patient Authorized Email Address (please print) Patient Name (please print) Date of Birth Signature Date San Antonio, Texas 78248 9