Patient / Guarantor Information Date: Patient's Legal Name: DOB: / / Address: City: ST: Zip: Home Phone: Cell Phone: Which phone number do you prefer we use? E-mail Address (Required for Patient Portal Access): Social Security #: / / Patient / Guarantor Employer: Work Ph: Employer Address: City: ST: Zip: Primary Care Physician: Referred by: Emergency Contact: Ph#: Single Married Divorced Widowed Spouse Name: Primary Pharmacy: Spouse / Parent / Other Information Name: Relationship: DOB: / / Home Phone: Cell Phone: Work Phone: Address: City: ST: Zip: Employer: Insurance Primary Insurance: Primary Policyholder Name: DOB: / / Secondary Insurance: Secondary Policyholder Name: DOB: / /
Authorization For Treatment and Communication I hereby voluntarily consent to medical care, including diagnostic and medical treatment, by Complete Endocrinology s providers. I acknowledge that no guarantees have been made to me as to the result of treatments or examinations in this medical practice. By providing my e-mail, cellular, landline, or any other numbers, I consent to receiving communications from Complete Endocrinology at any number or e-mail I provide which may identify the name of this office or service provider sending the communication and could disclose the nature of the communications. Complete Endocrinology may use this information to contact me by live agent, voicemail, e-mail, text message, auto-dialer or other computer assisted technology, pre-recorded message(s), or any other form of electronic communication for, but not limited to, appointment and follow-up health care reminders, scheduling, and billing reminders. I agree to update my contact information if it changes. Patient / Guarantor Signature: Date: *We use an automated reminder system, so please let us know your contact preferences and if you feel that you are receiving too many reminders. We will strive to make adjustments to meet your needs. Release of Information Under the Hipaa Privacy Rule (45 CFR 164.506), we are permitted to use and disclose your protected health information for treatment, payment and health care operations activities. This may include disclosing your health information to other healthcare providers outside of our office that are involved in your care. You have the right to request restrictions for the use and disclosure of your protected health information for treatment, payment or health care operations. Please let us know if you would like to request a restriction and we will provide you with the appropriate form to complete. Assignment of Benefits I agree that Complete Endocrinology will bill and provide necessary health information to any Payers. Payers are any health insurance plans or policies, private or government, that may pay all or part of the charges I have incurred. I hereby assign, transfer and set over to Complete Endocrinology all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I understand that I am responsible to pay any charges not paid by the Payer, including but not limited to, co-pays, deductibles, co-insurance and non-covered services. If I am a Medicare beneficiary, I request that payment of authorized Medicare benefits be made on my behalf to Complete Endocrinology for any services furnished to me. I authorize any holder of medical information about me permission to release to CMS and its agents, any information needed to determine these benefits for related services. If applicable, I also authorize payment of my Medigap and/or Secondary Insurance benefits to Complete Endocrinology for all claims filed on my behalf. This authorization applies to all services until it is revoked by me or my representative Patient / Guarantor Signature: Date:
Financial Policy and Procedures Welcome to our clinic. The physicians and staff at Complete Endocrinology feel that we can better serve your health care needs and avoid potential miscommunications by making you aware of the following financial policies and procedures. Insurance: Complete Endocrinology participates with most insurance companies, but it is your responsibility to verify your coverage with your insurance carrier directly. As a courtesy, we will file claims on your behalf. It is very important that you provide us with accurate insurance and policy holder information. All co-pays will be collected before your visit. You are responsible for paying any charges not covered by your insurance company, as well as, any deductible, co-insurance, or co-pay. Your Responsibility: It is necessary for you to know what benefits your insurance plan provides for you. Not all services provided are covered by every plan. Many insurance plans require you to use certain hospitals or doctors and may require pre-certification or referrals. We are not responsible if you are sent to a facility that is not covered by your insurance or if there is no referral on file with your insurance company. It is your responsibility to know which doctor or hospital your plan requires you to use and whether you need a referral. If your medical care is the result of a work-related injury, it is your responsibility to complete any necessary forms to allow us to release information to your employer or the workers compensation carrier. Private Pay: If you do not have insurance, you will be required to pay a minimum down payment on the date of service of $100 for your first visit and $75 for subsequent visits. This does not represent the possible total charges for your appointment. It is a prepayment towards your potential balance. The remaining balance will be invoiced to you. Additional Services: You may be billed by outside entities or other physicians for professional services including, but not limited to, lab, radiology or pathology. It is your responsibility to check coverage with your insurance carrier for these services. We can send orders to the provider or entity of your choice. If you are unsure of where tests will be sent, please ask. We are happy to assist you in getting the information you need to verify coverage with your insurance carrier. PLEASE NOTE: Unless otherwise specified, all labs that are drawn in our clinic are sent to LabCorp Nebraska. Statements: Complete Endocrinology will send you a monthly statement for any outstanding charges. Payment is due upon receipt of the monthly statement. Payments: We accept cash, personal checks, and credit card. A service fee of $20 will be charged for all returned checks. Accounts not paid in full within 90 days are considered past due. If you cannot make regular payments, please contact us. We require a monthly payment on all overdue accounts to keep your account in good standing. It is your responsibility to contact us to discuss payment arrangements. Cancellation Policy: At least 24 hours notice is required to cancel your appointment. Failure to notify us within 24 hours of a cancellation will result in a no show. Since we understand that this will happen from time to time, we do allow 3 no shows before we are unable to set up future appointments for you. I have received and agree to the Financial Policy and Procedures of Complete Endocrinology. Patient / Guarantor Signature: Date:
Release of Information Please list any family members or friends who may be involved in coordinating your care or discussing your bill. If not listed on this form we will not be able to discuss anything with them. I authorize Complete Endocrinology to discuss my medical information with the following: Name: Relationship to Patient: We will continue to rely on the information on this form when communicating with family members or others involved in your care unless you request changes. Please promptly notify Complete Endocrinology if you wish to alter the designations above. Patient / Guarantor Signature: Date: Notice of Privacy Practices Patient Acknowledgment of Receipt I, acknowledge that I received a copy or was offered a copy of The Complete Endocrinology Notice of Privacy Practices dated 9/9/2014. Patient / Representative Signature Date Relationship to Patient For Office Use Only: Patient, or patient representative did not sign the acknowledgment for the following reason(s): Refused Refused, stating that he/she has already signed an acknowledgment Unable to sign because of medical condition There was not a patient representative available to sign Other Witness Date
Authorization for Release of Health Information I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with NE State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. Complete Endocrinology uses SureScripts, Inc., a prescription system that allows prescriptions and related information to be exchanged between my providers and the pharmacy. The information sent between these systems may include details of any and all prescription drugs I am currently taking and/or have taken in the past. This information will be utilized by Complete Endocrinology. 2. This authorization may include disclosure of prescription information related to alcohol and drug abuse, mental health treatment, and/or confidential HIV related information by SureScripts, Inc. to Complete Endocrinology. 3. I have the right to revoke this authorization at any time by writing Complete Endocrinology. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. Signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be re-disclosed by the recipient, and this redisclosure may no longer be protected by state or federal law. 6. This authorization expires one year from the date of my signature below. 7. This authorization does not authorize Complete Endocrinology to discuss my health information or medical care with anyone other than those permitted under applicable law. Printed Name of Patient (or representative authorized by law): Date of Birth: Signature of Patient (or representative authorized by law): Date: Relationship to Patient (if applicable): Witness Signature: Date:
Care Team Please list primary care providers and specialists involved in your care whom you would like to receive copies of your clinical notes and labs done at Complete Endocrinology: Review of Systems Please circle if you have any of the following symptoms, and if present please provide additional information: excess weight gain, excess weight loss, loss of appetite, fever, diminished activity, fatigue eye pain, blurry vision, eye redness, eye itchiness, eye swelling, eye discharge, eyes bulging out, seeing double images ear pain, hearing loss, sinus pressure, swelling, congestion, sore throat, hoarseness, mouth lesions, foul smelling breath, sneezing, runny nose chest pain, rapid heart rate cough, bark-like cough, wheezing, chest tightness, pain with respiration, noisy breathing, rapid respirations, difficulty breathing difficulty swallowing, abdominal pain, nausea, vomiting, diarrhea, constipation, blood in stools blood in the urine, pain during urination, increased frequency of urination, voiding urgency, vaginal discharge, heavy menses, irregular menses, no menses, pelvic pain soft tissue swelling, joint swelling, limited motion, previous injuries, muscle aches itchy skin, dry skin, flaking, redness, rash, hives, skin lesions, swelling, bruising, insect bites, brownish discoloration of skin around neck or underarms numbness, weakness, tingling, burning, shooting pain, headache, dizziness, loss of consciousness increased thirst, heat or cold intolerance
**If you have completed the information below online via our patient portal you do NOT need to repeat this. If you have not signed up for our patient portal we encourage you to consider this as it allows you to access your medical records, communicate directly with your physician via email, and update your medical chart. All we need is your preferred email address.** Social History Are you a smoker? Y or N If yes, how long have you smoked and how much? Do you consume alcohol? Y or N If yes, what do you drink, how much and how often? Do you use illegal drugs? Y or N If yes, what drugs, how much and how often? Are you employed? Y or N If yes, what is your occupation? If no, are you on disability? What is your sexual orientation? Do you live alone or with others? Past Medical History Please list your medical conditions (ex: hypertension, heart disease, depression, GERD, osteoporosis, hypothyroidism ) Past Surgical History Please list your surgeries and age or year you had your surgery:
Family History: Medical Problems Surgeries Age of Death Mother Father Sibling (s) Children Medications: Medication Dosage Time of day medication taken Reason you take this medication Allergies: Medication Reaction