Primary Insurance Patient Information

Transcription

1 Dr. Russell O. Schub, F.A.C.P. Tel Board Certified Gastroenterologist Fax Centre Park Drive, Suite D Columbia, MD New Patient Established Patient Date Acct# (for office use only) Patient Name Last Name First Name Full Middle Name Date of Birth / / Age Sex Male Female Primary Insurance Patient Information Social Security number - - Home Address Home Phone ( ) Primary Care Physician (PCP) Last Name First Name Work Phone ( ) PCP s Phone Number( ) Cell Phone ( ) Emergency Contact Your Employer Full-time Part-Time Retired How were you referred to our practice? Physician, Name Family Website Insurance Carrier Claims Address Policy Holder Information Relationship Phone Insurance Friend Other Member Id # Group # Name Last Name First Name Full Middle Name Date of Birth / / Sex Male Female Social Security Number - - Employer Full Time Part Time Retired Relation to Policy Holder Self Spouse Parent/Guardian Other (please specify) Insurance Carrier Member Id # Secondary Insurance Claims Address Policy Holder Information Group # Name Last Name First Name Full Middle Name Date of Birth / / Sex Male Female Social Security Number - - Employer Full Time Part Time Retired Relation to Policy Holder Self Spouse Parent/Guardian Other (please specify) Revised 6/2012/ss

2 ASSIGNMENT OF BENEFITS & PAYMENT/CREDIT AGREEMENT (This is necessary to facilitate the processing of insurance claims and assure payment.) 1. I hereby authorize and give permission for Dr. Russell O. Schub, P.A.,Advanced Endoscopy Center of Howard County, LLC and Advanced Anesthesia, LLC to disclose my personal health information (PHI)* for insurance and treatment purposes only. I am allowing Dr. Russell O. Schub, P.A., Advanced Endoscopy Center of Howard County, LLC and Advanced Anesthesia, LLC to release all PHI (private health information) necessary for payment and treatment of my specific health problem. 2. I hereby assign to you, my doctor, all medical and surgical benefits to which I am entitled, including Medicare, private insurance and any other insurance. 3. I understand that I am financially responsible for all charges not paid by said insurance company, including any deductibles and co-pays, and that payments are due at the time services are rendered. 4. I understand and agree that in the event that I fail to make payment for services rendered to me, my name and account may be turned over to an attorney or collection agency and I agree to pay collection agency s fees for collection, court costs, and/or reasonable attorney fees that may be incurred in the collection of an outstanding balance. 5. This office reserves the right to charge a handling fee for any unpaid balance. Acknowledgement of Receipt of Privacy Notice I have been presented with a copy of this provider s Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state law. I understand the contents of the notice, and, subject to the following restriction(s) I have made concerning my personal medical information, I agree to the disclosures named in the notice. Federal Law ensures the privacy of your medical records, their availability to you, and specific rights regarding your medical records. Dr. Russell O. Schub, P.A., Advanced Endoscopy Center of Howard County, LLC and Advanced Anesthesia, LLC comply with these standards. As a general principle, we will always assume that you have instructed us NOT to release your medical records, or any portion thereof, to anyone, except under the usual, general circumstances covered below. Please read and sign this GENERAL AUTHORIZATION CONCERNING YOUR MEDICAL RECORDS. Relevant portions of my medical record may be provided to 1. other designated doctors and their staffs (e.g., this practice; primary or referring doctors and their staffs; hospitals or outpatient facilities, endoscopy unit, or surgical-day-care). 2. my medical insurance company to document specific service(s) provided and billed. 3. the Government, as required by law (e.g., subpoena) If you wish to designate (a) person(s) (such as a spouse, significant other or family member) (other than those listed above) to be given access to all or part of your medical record, please write their name(s) below Name(s) If you have any questions, comments or exceptions, please speak with our Practice Administrator. I acknowledge that I have read, understand, and agree to the above information regarding benefits and payment/credit agreement, privacy notice and medical records. Printed Name Date Signature Account No. (Office Use Only) rev. 2/2011

3 Patient Information Name Date MRN (for office use only) Date of Birth Age Race: White/Caucasian Black/African American Hispanic/Latino Asian Na ve Hawaiian/Pacific Islander Other Pa ent Declines to provide Ethnicity: Hispanic/La no Not Hispanic/La no Pa ent Declines to provide Preferred Language Past or Present Medical Conditions- Please check any past or present medical conditions Anal Fissure Cirrhosis of Liver Glaucoma Irritable Bowel Syndrome Reflux/GERD Anemia Colitis Gout Jaundice Rheumatic Fever Anesthesia Complications Breathing Colon Cancer Heart Attack Kidney Disease Seizures Anesthesia Complications Sexually Transmitted Colon Polyps Heart Failure Kidney Failure Nausea/Vomiting Diseases Arthritis Crohn s Disease Heart Murmur Kidney Infection Skin Cancer Asthma Depression Hemorrhoids Kidney Stone Sleep Apnea Atrial fibrillation Diabetes Hepatitis A Lung Cancer Spine/Back Problems Back pain Diverticulitis Hepatitis B Migraines Stomach Ulcers Bladder Disease Duodenal Ulcer Hepatitis C Milk Intolerance Stroke Bleeding Disorder Easy Bruising Herpes Zoster Mouth Ulcers TB (Tuberculosis) Blood Cancer Eczema Hiatal Hernia Osteoporosis TB Skin Test Positive Bone Fracture Emphysema High Blood Pressure Pancreatitis Thyroid Disease Hyper Brain Cancer Esophageal Stricture High Triglycerides Paralysis Thyroid Disease Hypo Bronchitis Fatty Liver HIV/AIDS Parkinson s Disease Ulcerative Colitis Celiac Disease Frequent Urinary Infections Hives Phlebitis Chronic Lung Disease Gall Stones Irregular Heartbeat Prostate Other Other Other Other Urinary/Bladder Infections Valvular Heart Disease Varices of Esophagus/Stomach Previous Surgeries Anal Fissure Surgery Cardiac surgery Angioplasty C-Section When Appendectomy Cholecystectomy-gall bladder removal Cardiac defibrillator Colon Resection Gastric By-Pass Hernia Repair- Abdominal Lysis of Adhesions Heart Valve Replacement Hiatal Hernia Repair Obesity Surgery When Hemorrhoidectomy Hysterectomy Pacemaker Liver Resection Prostatectomy When Other Previous Procedures Colonoscopy Upper Endoscopy (EGD) ERCP Endoscopic US-internal gall bladder ultrasound Liver Biopsy

4 Review of Systems Please circle any symptoms you are currently having Allergic/ Immunologic Gastrointestinal Musculoskeletal Persistent infections Abdominal bloating/swelling Arthritis Allergic reaction- wheeze,hive,itching Abdominal cramping Back pain Abdominal pain Joint deformity Constitutional Anal pain Joint pain Chills Belching Joint swelling Fatigue Change in bowel habits Muscle pain Fever Constipation Muscle weakness Loss of appetite Dairy intolerance Stiffness Sweats Diarrhea Weight gain Excessive flatulence Skin Weight loss Heartburn Dryness Hemorrhoids Hives Ear, Nose, Mouth Throat Mucous in stool Itching Change in hearing Nausea Rashes Change in vision Pain with bowel movement Difficulty swallowing Poor appetite Endocrine Dizziness Rectal bleeding Excessive thirst Double vision Rectal pain Hair loss Ear pain Rectal Urgency Heat intolerance Mouth Ulcers Regurgitation Cold Intolerance Nasal Obstruction Soiling of Stools/Bowels Sore throat Trouble swallowing Hematologic/lymphatic Yellowing of skin/eyes Bleeding gums Cardiovascular Vomiting Easy bruising Ankle swelling Vomiting Blood Enlarged lymph glands Chest pain Wheat/Gluten intolerance Prolonged bleeding Heart murmur Irregular heart beats Genitourinary Psychiatric Palpitations Blood in urine Anxiety Shortness of breath with exertion Dark urine Depression Decrease in urine flow Difficulty sleeping Respiratory Discharge Hallucinations Cough Frequent urinary infections Loss of interest in enjoyed activities Excessive sputum Frequent urination Nervousness Shortness of breath Incontinence Panic attacks Wheezing Nighttime urination Paranoia Bloody sputum Painful urination Suicidal thoughts Pain with intercourse Other Neurological Sexual difficulty Dizziness Females Fainting Date of last menstrual period Other past medical problems Frequent headaches Are you pregnant or could you be Pregnant? Memory loss Heavy periods Migraine Breast lump(s) Numbness or tingling Males Paralysis Prostate problems Seizures Testicle problems Tremors Vertigo

5 Lab or radiology testing recently done Other Allergies No known allergies No known drug allergies Aspirin Codeine Diprovan/Propofol Fentanyl Iodine Latex Penicillins Sulfa Valium Versed Other Other Other Food Allergies Egg Nuts Soy Other Social History Occupation Number of children Marital Status Single Married Divorced Widowed Tobacco Smoking Status - please include type, quantity and frequency Current every day smoker Current occasional smoker Former smoker Never smoked Type Started Quit Quantity Frequency Alcohol Beer Quantity Frequency Wine Quantity Frequency Alcohol Quantity Frequency Caffeine Coffee Soda Tea Energy Drink Quantity Frequency Drug Use-Recreational Type Quantity Frequency Family Medical History No knowledge of family medical history Health status Mother Father Sister Brother Grandmothermaternal Grandmotherpaternal Grandfathermaternal Grandfatherpaternal Healthy Ill/Poor Health Deceased at Age Breast Cancer Celiac Sprue Colitis Colon Cancer Crohn s Disease Diabetes Esophageal Cancer Heart Disease High Blood Pressure Liver Disease Pancreatic Cancer Stomach Cancer Other Other Other

6 Medication List Name Date of Birth Today s Date Please complete the information below and bring this form with you to your appointment. List all current medications that you currently take, including vitamins, over-the-counter medications and herbal preparations. Make sure to include dosage and frequency Medication Name (Please Print Legibly) Dosage (mg) Frequency (how often per day) Check if need refill Please fill out the pharmacy information completely, this information is used to electronically send your prescriptions. Pharmacy Name Pharmacy Phone Number Pharmacy Address *****The above information is complete, true and correct to the best of my belief.***** Signature Signature Date Rev. 6/12