Dr. Osvaldo Anez 462 Herndon Pkwy. Ste. # 101 Herndon, VA Fax:

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1 Dr. Osvaldo Anez 462 Herndon Pkwy. Ste. # 101 Herndon, VA Fax: Reason for visit: DO YOU HAVE A LIVING WILL? YES NO FIRST NAME M.I. LAST NAME MAIDEN NAME SOCIAL SECURITY # DATE OF BIRTH HOME ADDRESS APT # CITY STATE ZIP HOME PHONE RACE REFERRED BY: FIRST AND LAST NAME CELL PHONE EMPLOYER WORK STATUS - SELECT ONE WORK PHONE FULL TIME PART TIME RETIRED DISABLED PERSONAL PHYSICIAN NAME/PHONE # ( ) -- MARITAL STATUS S M W D SPOUSE'S NAME EMPLOYER SPOUSE WORK PHONE# PERSON TO CONTACT IN CASE OF EMERGENCY EMERGENCY CONTACT PHONE # **PLEASE COMPLETE ALL INSURANCE INFORMATION BELOW. DO NOT LEAVE BLANK.** Primary Insurance Insurance Company: Address City, State, ZIP Phone # ID# Secondary Insurance Insurance Company: Address City, State, ZIP Phone # ID# Group# Employer Name: Group# Employer Name: Policy holder NAME & DOB Policy holder NAME & DOB Policy holder SS# Policy holder SS# Payment Policy All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. The patient is responsible for all fees, regardless of insurance coverage. Payment is due when services are rendered unless other arrangements have been made in advance with our office. You agree to reimburse provider the feesof any collection agency, which may be based on a percentage at a maximum of 35% of the debt, which fee shall be added at the time of placement with the collection agency, and all costs, and expenses, including reasonable attorney's fees we incur in such collection efforts. Bariatric patients are subject to a $200 non refundable program fee. Insurance Authorization and Assignment I hereby authorize Dr. Anez to furnish information to insurance carriers (including Medicare/Medigap) concerning my illness and treatment and I hereby assign to the physician all payments for medical services rendered to myself or my dependents. I understand that I am responsible for the amount not covered by my insurance. PATIENT INITIALS: I understand that I will be responsible for a charge of $50.00 for missed appointments without at least 24 hours prior cancellation notice. I certify that the information I provided above is correct. All insufficient checks will incur a $25.00 return check fee. Date Signature I acknowledge that I have been offered a copy of the privacy notice of Dr. Anez. Copy Taken Copy Denied 1

2 DR. OSVALDO ANEZ 462 Herndon Parkway Suite 101, Herndon VA Tel: Fax: OFFICE POLICIES (Effective 1/1/2015) Office Hours are Monday-Thursday 9-5 with lunch from 12-1 and Friday Before the initial consultation it is the patient s responsibility to verify that their insurance policy does cover morbid obesity treatment. If Morbid Obesity coverage is not available, the patient will be billed the consultation fee. 2. Referrals are due at the time of each visit. It is the patient s responsibility to contact the insurance carrier to verify if a referral is needed. Patients without a referral will be rescheduled. 3. *PROGRAM FEE: A $ Non-Refundable Program/Administration Fee is required for Bariatric patients. The Program/Administrative fee covers all of the literature given to the patient in regards to our Bariatric services, Web Site services and all Surgical/Authorization paper work. This Program fee is due once we receive authorization from your insurance company & a surgery date is scheduled. This fee is not billable to the insurance companies. 4. Medicare patients receive an information packet that requires a signature. This is given to the patient if surgery is an option. 5. Returned check fee is $ Medical Requests are charged as followed: Base fee $15.00 and $.50 per page up to 50 pages, $.25 each page over 50 pages. Postage is additional. Fax requests require a medical release signed and it has to be fewer than 30 pages. 7. FMLA/Short-term disability; Patient s responsibility; Turn in all necessary forms to be completed by our Physician staff. Allow 1-2 weeks for form completion. When your forms are complete our office staff will notify you. Please include a stamped self-addressed envelope if you wish to receive them completed by mail. 8. AFTER HOURS FEE: There is a fee that will be assessed to the patient s account if non-urgent calls are placed after hours. 9. The patient is responsible for any collection fees incurred on past due balances. 10. Dr. Raphael Canadas is Dr. Anez s surgical assistant. His surgical fee is $800 for Bariatric Surgery (Roux en Y Gastric Bypass). Dr. Canadas will bill your insurance company his surgical fee after surgery. Please call your insurance company to verify if Dr. Canadas participates with your insurance plan or if you have out-of-network benefits that may cover his charges. If you DO NOT have coverage for the assistant surgeon, contact Dr Canadas office at (703) , prior to surgery, to discuss his fee and possible payment plans. Payment received by Dr. Canadas from your insurance company may be accepted as full payment for his assistant surgeon fees. 11. A $25 fee will be charged for all Work Related/Disability forms need to be filled out. I (patient) have read and do understand the entirety of the Office Policies. I agree to the terms and conditions of sections (1-8). I am fully aware of the Non-Refundable Program Fee and agree to all of the conditions that are noted in the policy given to me from the office staff at my initial consultation. Print Patient Name: Patient Signature: Date: / / 2

3 OSVALDO ANEZ MD. FACS. FICS. 462 Herndon Parkway, # 101, Herndon, Va Tel: Fax: SLEEP APNEA SCREENING AND ORDER FORM Patient Name: Sex: M F Date of Birth: SS#: Phone #: Home: Work: Cell: Tests: Requested Completed Diagnostic Polysomnogram (Sleep Study) Split Night (Combined Poly and CPAP/Bi-level Titration) CPAP/Bi-level Titration MSLT (Multiple Sleep Latency Test) Reason for Study: Past Medical History: Daytime Sleepiness with Apnea Cardiovascular Disease Daytime Sleepiness with Morbid Obesity Diabetes Morbid Obesity Pulmonary Disease Other Other Patient Questionnaire What is Sleep Apnea? Sleep apnea is the most common form of Sleep Disordered Breathing (SDB); a general term for a variety of breathing difficulties that occur during sleep. Sleep apnea is when a person experiences irregular breathing during sleep. Sleep patterns are disrupted resulting in daytime sleepiness and fatigue. Snoring is a warning sign of sleep apnea. You will hear loud snoring followed by periods of silence. There may be a loud snort or gasp as breathing restarts. This could happen hundreds of times per night. 1. I have been told that I snore. 2. I am overweight. 3. I have high blood pressure. 4. I tend to sweat excessively during my sleep. 5. I tend to fall asleep during in appropriate times. 6. I frequently awaken with headaches in the morning. 7. Others and/or I have noticed a recent change in my personality. 8. I am always sleepy during the day even if I slept throughout the night. 9. I have been told that I sleep restlessly. I am always tossing and turning. 10.I have been told that I stop breathing when I sleep without recollection. TOTAL CHECKED POSITIVE Scoring: If you have checked 3 or more boxes, you show symptoms of sleep apnea and should have a sleep study completed before surgery. Please call to schedule an appointment: Your PCP for referral Referring Physician: Dr. Anez Signature: Date: Fax Completed Form To: Dr. Anez s Office: 703/

4 OSVALDO ANEZ MD. FACS. FICS. 462 Herndon Pkwy Ste. # 101 Herndon, VA Phone FAX NOTICE OF PRIVACY PRACTICE - HIPAA This notice describes how medical information about you may be used and disclosed. Each time you visit this office, a record of this contact is made. This information serves as a Basis for planning your care and treatment, Means of communication among the many health professionals who contribute to your care, Legal document describing the care you received, Means by which you or a third-party payer can verify that services billed were actually provided, A source of data for education, research and planning, A source of information for public health officials charged with improving the health of the nation, A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve, A tool so that we know who we can contact with your personal information. PERMISSION TO CONTACT May we leave a message on your home answering machine? YES NO May we leave a message with your family members? YES NO May we call your work and speak with you or leave a message? YES NO May we call your cell phone? YES NO May we contact you by ? YES NO Date: Patient Name: Signature: 4

5 OSVALDO ANEZ MD. FACS. FICS. 462 Herndon Pkwy. Ste. # 101 Herndon, VA Tel: Fax: EXPECTATIONS Moving forward with your surgery can at times seem daunting. The information below will help you better prepare for your surgery. When you make the decision to have gastric bypass surgery, you will be responsible for a $200 program fee which is explained on the office policies. This fee is non-refundable. We will contact your insurance to verify that your plan covers weight loss surgery. If it is not a benefit, they will not cover the surgery or any of the related procedures/tests. If you have the surgery coverage, we will explain what the requirements are in order to get your surgery approved. If the insurance requires certain documentation or evaluations, we will not submit your authorization request until all applicable documentation is received by our office from you. Once your surgery procedure is approved, we will move forward on setting a surgery date. Surgery will not be scheduled sooner than 6 weeks from when we receive authorization. You will come back into the office for a 2 nd visit around 6 weeks before surgery. During this visit, you will speak with the Surgical Coordinator to discuss your pre-operative orders and confirm your surgery information. You will be scheduled for another office visit at this time to come back for your 3 rd office visit. The month before surgery will be a very busy time for you. We will refer you to work with the Bariatric Coordinator at INOVA Fair Oaks Hospital. This person is available to help you schedule your pre-operative testing. Be sure to keep your calendar accessible when scheduling your appointments. Being organized is very important during this time. Your pre-operative testing must be completed at least one to two weeks prior to surgery. You will return to the office two weeks before surgery to speak with Dr. Anez about the results of your tests, to discuss final questions and review pre- and post-operative instructions. After weight loss surgery, you will require frequent visits the first two years; after that, you will see us annually. It is your responsibility to stay current on your appointments. It is essential to have lab work done for each visit to ensure you are getting the proper nutrition and supplementation. You may obtain a lab slip from the office to have these tests done and the results will be available on your appointment day. Alternatively you may have labs drawn in the office (PPO policies only) the day of your visit and receive a call with the results. Best wishes on your new journey! Obesity Surgery Center Staff 5

6 OSVALDO ANEZ, M.D., F.A.C.S., F.I.C.S. 462 Herndon Parkway, Suite 101 Herndon, VA PHONE: FAX: PATIENT INSTRUCTIONS FOR PSYCHOLOGICAL EVALUATION Instructions: The guidelines below can assist you in obtaining the appropriate psychological evaluation needed prior to scheduling bariatric surgery. Bring this document with you to your appointment for psychological evaluation. I. WHO SHOULD PERFORM THE PSYCHOLOGICAL EVALUATION? A licensed psychiatrist (M.D.), licensed clinical psychologist (Ph.D.), or Masters-level social worker who has significant experience in psychological testing. II. WHAT SHOULD THE PSYCHOLOGICAL EVALUATION INCLUDE? An evaluation should include you completing an acceptable assessment tool such as the Minnesota Multiphasic Personality Inventory (MMPI), the Million Behavioral Inventory, or comparable assessment, which should be completed in a supervised setting. After completing the assessment, the psychiatrist or psychologist should engage in an evaluation session with you, using the assessment results. III. WHAT SHOULD THE PYSCHOLOGICAL REPORT INCLUDE? There is certain information which should be included in the report, at minimum: A. Patient Information: Name, Sex, Age, DOB, Address, Occupation B. Referring physician s name: If you are a member of HMO or PPO, this should be your primary care physician; otherwise, your surgeon is the referring physician. C. Reasons for Referral: Assessment of: Patient s motivation for gastric bypass or gastric banding surgery. The likelihood of post-operative compliance in all respects, including dietary restrictions and behavior modification. The likelihood of post-operative cooperation. D. Psychological History: Marital History Family History Personal History Weight history, including weight loss history History of addictive behaviors, including alcohol and drug abuse, anorexia and bulimia. ALL SUBSTANCE ABUSE HISTORY. E. Assessment: Results indicating which assessment tool was used and results F. Recommendation: Is the patient motivated to have surgery to correct the weight problem? Will the patient likely comply with post-operative requirements? Is additional psychological support needed? Is bariatric surgery advisable by the psychologist or psychiatrist? Does the patient fully understand the risks, alternatives, and possible complications associated with the proposed surgical procedure? *** I RECOMMEND THAT HE/SHE HAVE THE SURGERY. Please fax evaluations as soon as possible to (703)

7 OSVALDO ANEZ, MD, FACS. WELCOME Please fill out this form to the best of your knowledge. It will help us in your future care NAME: DOB: AGE: TODAY S DATE: RACE SEX Ht: Wt: BMI: IDEAL WT: Referring Physician: Phone: Fax: Have you ever been admitted to a psychiatric institution? Yes: No: If Yes, When: For how long: Reason: Do you feel you have a helpful support system around you? Yes No PAST HX & CO-MORBID CONDITIONS High Cholesterol Diabetes.. Pain in Joints/Multi Sites Acid Reflux.. High Triglycerides. Thyroid Problems.. Urinary Incontinence Peptic Ulcer Disease Hypertension... Gallstones Asthma.... Hiatal Hernia Heart Disease.. Breast Cancer Shortness of Breath. Anemia.. Ankle Swelling Uterine/Cervical CA.. Sleep Apnea. Blood Clot. Depression Arthritis Snoring. Other... PAST SURGERIES: MEDICATION: NAME DOSE/ FREQUENCY REASON ALLERGIES: FAMILY HISTORY: Obesity: (list relatives) Cancer: HTN: Diabetes: Heart Disease: SOCIAL HISTORY: Marital Status: ( M), (D), (S), (W). Children Occupation: Dress/Pant size: Do you smoke? Yes: No: If yes, how long, how many per day? Do you drink alcohol? Yes: No: If yes, what, how much, how long? Are you currently exercising? Yes: No: If yes, how often? Are you a Sweet Eater Yes: No: Snacks: Yes: No: Big Eater: Yes: No: PHYSICAL EXAM: CV: S1&S2 WNL. LUNGS: Clear. ABDOMEN: Soft, non-tender, no masses. BP PULSE EXTREMITIES: No edema, no signs of DVT. Required Consults/Tests Pre-op: Cardiac Clearance Psychological Clearance Pulmonary Clearance Sleep Study Hematology Endocrinology Medical (PCP) GI for EGD Other: 7

8 NON-SURGICAL EFFORTS AT WEIGHT LOSS DATES (range) PROGRAM/DIET/BEHAVIOR WT. LOST WT. REGAINED Protein diet (Atkin s, South Beach) Weight Watchers Over-Eaters Anonymous Jenny Craig Diet Pills/Shots MD. Supervised Curves Hypnosis Nutri-System Registered Dietitian Starvation Laxatives Liquid Fast i.e. Optifast Other The above is true and correct to the best of my knowledge. Patient Signature ASSESSMENT: MORBID OBESITY WITH COMPLICATIONS, RECOMMENDATIONS: Roux-en-Y Gastric Bypass, Robotic Sleeve Resection. (Diet, behavior modification imposed as well as potential complications and benefits were explained to the patient and he/she understood). Provider Name/ Signature Date 8

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