Mid-Atlantic Headache Institute

Transcription

1 Mid-Atlantic Headache Institute 1) We DO NOT participate with insurance companies other than MediCare, or Tricare. Please contact your insurance company to determine what you may submit for reimbusement. The cost of your visit is due at the time of service. We do not see workman s comp or accident cases. Patient Responsibilities To better serve you, please observe the following with regard to the practice: Appointments: Always be on time, allowing 30 minutes for paperwork for initial appointments. Arriving late may be considered a no show and appointment rescheduled. A $20 annual administrative fee will be collected for patients with MediCare, Or Tricare. Bring test results such as MRIs, x-rays, blood tests and any other tests in your possession, as well as previous medical records and all your medications. If you are required to have tests, be sure to give the laboratory or testing center of your choice our fax number or address for forwarding test results. Fax: / Commerce Center West Reisterstown Road, Suite 104 Pikesville, Maryland Please call well in advance for routine appointments (3 months). Our appointments fill very quickly. We try to accomodate appointments for urgent problems as quickly as possible. Telephone Calls : When leaving messages on the telephone be sure to speak slowly. Leave your name (with spelling), telephone number, pharmacy phone number and fax and your date of birth. Call for prescription refills during regular office hours. No refills of medication will be given after hours or on weekends. Controlled substances cannot be refilled over the telephone. Refills will be called in within 48 hours of request. We need the pharmacy phone number, the name, dosage and quantity of medication requested. Refills requests cannot be filled if you have not been seen in the office within a reasonable time period. Call your pharmacy and request that they fax us a refill form for your refill requests. Call to check on the status of your test results (blood work, x-rays, MRI, etc.). We will contact you ONLY if any abnormalities are found. Telephone visits are not covered by insurance and will be charged directly to the patient. Please discuss the fee when making the appointment. Financial: As previously stated, payment is due at the time of service. Appointments not cancelled at least 24 hours before scheduled will result in a no show/ no cancellation fee equal to the cost of the visits. Future appointments will not be honored until paid. There is a $40 fee for returned checks. Future check payments will not be accepted. Accounts sent to collection will subject to additional collection fees charged by the collection agency. There will be a charge for completion of forms (FMLA, Disability, etc.) Thank you for your cooperation and for allowing us to participate in your medical treatment. Patient Signature: Date: Relationship to patient (if signed by personal representative):

2 Mid-Atlantic Headache Institute Effective Date: September 18, 2013 Notice of Privacy Practices This notice describes how medical information about you may be used, disclosed and how you can get access to this information. Please read it carefully. Understanding your health record A record is made each time you visit this office. Your symptoms, examination and test results, diagnosis, treatment and care plan are recorded. This information is most often referred to as your health or medical record and serves as a basis for planning your continued care and treatment. It also serves as a means of communication among any and all other health care professional who may contribute to your care. Understanding what information is retained in your record and how that information may be used will help you to ensure its accuracy and enable you to relate to who, what, where and why others may be allowed access to your health information. This effort is being made to assist you in making informed decisions before authorizing the disclosure of your medical information to others. Use or disclosure of your health information will follow the more stringent of State or Federal laws. Understanding your health information rights Your health record is the physical property of the health care practitioner or facility that completed it but the content is about you and therefore belongs to you. You have the right to request restrictions on certain uses and disclosures of your information and to request amendments be made to your health record. Your rights include being able to review or obtain a paper copy of your health information and to be given an account of all disclosures. You may also request communications of your health information be made by alternative means or to alternative locations. Other than activity that has already occurred, you may revoke any further authorizations to use or disclose you health information. Any breach of confidentiality will be reported to the patient by mail. This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice s current Notice of Privacy Practices on request. Signature: Date: Relationship to patient (if signed by personal representative):

3 Mid-Atlantic Headache Institute Patient Information Sheet NEW CHANGE Date: Patient Name: Date of Birth: Patient Address: City: State: Zip: Work: Mobile: Social Sercurity Number: Guarantor: Male Female (circle one) Relationship: Guarantor Place of Employment: Employer Address: Emergency Contact: Primary Care Physician: PCP Address: Fax: Pharmacy Information: Address: Fax: MediCare / Tricare Patients Only. Primary Insurance Carrier Carrier: Carrier Policy Holder Date of Birth: Policy Holder Place of Employment Policy Number: Group Number: Policy Holder: Self Spouse Dependant I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR THE PAYMENT OF ALL CHARGES. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO MID ATLANTIC HEADACHE INSTITUTE AND WILL BE RESPONSIBLE FOR ANY PATIENT LIABILITY BALANCE NOT PAID BY INSURANCE, INCLUDING COLLECTION FEES. ALL COPAYS MUST BE PAID AT TIME OF SERVICE. Patient Signature: Date: Relationship to patient (if signed by personal representative):

4 Mid-Atlantic Headache Institute Patient Name: SS#: Date: Patient Address: Patient Medical History page 1 of 3 DOB: Age: City: State: Zip: Occupation: Work: Mobile: Parents Names: Marital Status Married Single Other Family Physician: Referring Physician: FAMILY HISTORY: If Living: Age Health If Deceased: Age Cause Father Mother Siblings Children Has any blood relative ever had the following: Diabetes Rheumatic Fever Cancer Heart Disease Asthma Stroke Tuberculosis Arthritis Mental Illness High BP Hay Fever Anemia Kidney Disease Epilepsy Migraine Bleeding Trend In the past year, has your general health been good? YES NO Have you ever had any of the following: Measles Chicken Pox Malaria Influenza Pneumonia Infect. Mono. Whopping Cough Scarlet Fever Meningitis Encephalitis Pleurisy Poliomyelitis Diphtheria Mumps Shingles Typhoid Fever Tuberculosis Unexp. Fever Have you ever had an operation? YES NO YEAR YEAR Tonsils Nose Eyes Ears Head Thyroid Heart Lungs Gallbladder Stomach Colon Appendix Breast Prostate Rectum Kidney Hernia Uterus YEAR Ovary Disc Other YEAR

5 Patient Medical History page 2 of 3 Have you ever been seriously injured? YES NO Have you ever had any of the following: Asthma Hay Fever Hives Allergies to medication (Penicillin, etc.) Other allergies Have you ever had any of these symptoms: Skin rash Prolonged Itching Easy bruising Recurring boils Yes No Have you ever had a headache? Was it mild and easily controlled? Has your eyesight been good? Have you had any infections or inflammation of the eye? Have you ever been told you have glaucoma or a cataract? Have you seen halos of rainbows around lights at night? Have you had any impairments of your hearing? Have you ever heard the following in your ears? Buzzing Ringing Hissing Have you had any pus or drainage from your ear? Have you had more than 2 colds in a year? Have you had the following? Frequent sore throats Tonsillitis Hoarseness Are your teeth in good repair? YES NO Have you experienced any of the following: Recurring pains or tight heavy pressure in your chest Frequent thumping or racing of your heart Feel your heart skip a beat Shortness of breath from 1 flight of stairs or slight incline Feel the need to take in a deep breath to get in more air Any noises or wheezing with your breathing Swelling of your feet or ankles Recent cough that has lasted more than 1 month Coughed up any blood Awaken at night with sweats or shortness of breath Must sleep propped up in order to breathe easier High Blood Pressure Heart murmur Yes No Have you ever been told you have had a heart attack? Have you had any convulsions, seizures or fits? Has your appetite been good? Has your digestion been good? Do your bowels move regularly? Had diarrhea, other than infreq. upset? Have you had any constipation? Any recent changed in bowel habits? Had any nausea/vomiting? Have you ever vomited blood? Have you ever had blood in your stool? Have you ever had mucus in your stool? Have your stools ever been: clay colored black-tarry Have bowel movements ever been painful? Do you have hemorrhoids? Have you ever had heartburn? Have you ever had trouble swallowing either liquids solid foods Have you had pain in the stomach/abdomen? Have you ever had excessive gas? Have you ever been told you have an ulcer? Have you ever had jaundice (yellow skin)? Have you ever had trouble passing urine? Pain or burning while urinating? Blood in urine? Black or coffee colored urine? Passed any stones? Have you had excessive thirst? Have you had excessive amounts of urine? Do you get up at night to urinate? Any decrease in the size/force of urine stream? Had you ever had the following in your urine: sugar pus albumin Have you ever had any of the following: Syphilis Gonorrhea Other venereal disease Blood test positive for Syphilis Blood test positive for HIV What is your usual? Weight lbs Height Has your weight been constant in the last year? Have you gained weight lost weight Amount lbs. Females: Age Menstruation began Are your periods regular? Any bleeding between periods? Date of last pelvic exam Were there any abnormalities found? Ever take birth control pills? Date of last period Gynecologist: Address: Yes No Yes No

6 Have you ever had any of the following: Unconsciousness Fainting Blacking out Dizzy Attacks Lightheadedness Backache Bone or Joint Aches Memory Failure Patient Medical History page 3 of 3 Weakness, Numbness, Tingling in Arms or Legs Aches in calves or thighs from walking which subside promptly with rest Are any of the following true for you: Are you a tense of nervous person? Do you have episodes when you feel tense and irritable and find it hard to relax? Do you have sweating or shaking of your hands? Knots or butterflies in your stomach? Any of the following feelings: Depressed Blue Melancholy If so, how would you classify these feelings? Mild Moderate Severe range of all Have you experienced crying spells? Had suicidal thoughts? Have experienced periods of fatigue? At what time of day? Do you consider yourself an unhappy person? Do you get along with your spouse? Having marital problems? Are you a perfectionist? Are you a worrier? Do you have other problems or difficulties? Are you generally comfortable at room temperature? Sweat more than normal? Sweat less than normal? Do you have dry skin or hair? What is the highest level of education you have completed? Grammar school College High School Graduate school What are your hobbies? If you are married: Spouse s name: Spouse s age: Is spouse in good health? Yes No Year married: Do you have children? Yes No Children s ages: Are your children in good health? Yes No Ever been divorced? Yes No Personal Habits: Do you drink any of the following: Coffee # cups/day Tea # cups/day Other caffeinated beverages Alcohol, if yes... Occasionally Moderately Heavily Do you use tobacco products? Yes No What: Frequency: Do you use any recreational drugs? Yes No What: Frequency: How many hours of sleep do you get at night? Do you exercise regularly? Yes No How frequently: Have you had anemia or any bleeding disorder? Yes No Have you ever been hospitalized for reasons other than surgery? Yes No If yes, please explain further: Nature of illness: Date of illness: Name of hospital: Have you ever had any of the following tests or examinations: Year Chest x-ray Skull x-ray Sinus x-ray Back x-ray Cervical Spine x-ray GI Series (stomach and sm intestine) Barium enema (colon & lg intestine) Gallbladder x-ray Intravenous pyelogram (kidney) Myelogram Arteriogram Electroencephalogram(Brain wave) MRI scan of the head CAT scan of the head Electrocardiogram Spinal Fluid exam Radioactive thyroid uptake exam Blood test for thyroid disturbances Liver function tests Glucose tolerance test (Diabetes) Immunizations you have had: Smallpox Tetanus Poliomyelitis Influenza Others General information: Personal Physician: Address: Therapist Name: Address: List any allergies: Fax: Fax:

7 Ticlid Plavix Aggrenox Coumadin / Pradaxa Ecotrin or Aspirin Aricept Exelon Reminyl Namenda Mestinon Bromocriptine Comtan Staleevo Amantadine Tasmar Requip Sinemet or Levodopa & Carbidopa Mirapex Eldepryl/Zelapar Neupro Azilect Desoxyn / Methamphetamine Concerta / Ritalin / Methylphenidate Adderal / Dextroamphetamine Focalin Strattera Vyvanse Xyrem Provigil / Nuvigil Blocadren or Timolol Corgard or Nadolol Inderal or Propanolol Lopressor / Metoprolol / Toprol Tenormin or Atenolol Bystolic Cardizem / Diltiazem Covera, Verelan, Calan, Verapamil Norvasc Procardia or Nifedipine Catapress or Clonidine Atacand Neurontin / Gabapentin Gralise / Horizant Lyrica Dilantin, Phenytek or Phenytoin Tegretol, Carbatrol or Carbamazepine Trileptal Depakote / Valproic Acid Topamax / Trokendi Gabitril Lamictal Zonegran Phenobarbital Mysoline or Primidone Zarontin Keppra Vimpat Fycompa Aptiom Please mark all medications used in the past Lorzone Zanaflex or Tizanidine Soma or Carisoprodol Baclofen / Lioresal Skelaxin or Metaxalone Amrix / Flexeril / Cyclobenzaprine / Fexmid Norflex or Orpenadrine Robaxin or Methocarbamol Xanax or Alprazolam Ativan or Lorazepam Valium or Diazepam Librium or Chlordiazepoxide Klonopin or Clonazepam Tranxene or Clorazepate Buspar/Buspirone Sonata Ambien Rozerem Restoril Halcion Doral Lunesta Silenor Antivert or Meclizine Benadryl or Diphehydramine Compazine or Prochlorperazine Reglan or Metoclopromide Tigan / Trimethobenzamide Zofran / Ondansetron Phenergan or Promethazine Thorazine or Chlorpromazine Vistaril or Hydroxyzine Prozac / Fluoxetine Zoloft / Sertraline Paxil Luvox Celexa / Lexapro Effexor / Pristiq Remeron Cymbalta Brintellix Savella / Fetzima Vilbryd Eskalith, Lithobid or Lithium Emsam Limbitrol Elavil or Amitriptyline Pamelor or Nortriptyline Trazodone Desipramine Tofranil or Imipramine Sinequin or doxepin Surmontil Vivactil Ludiomil / Maproptyline Wellbutrin or Bupropion Prednisone Solumedrol Depo-Medrol Dexamethasone / Medrol pack Decadron Zyprexa Geodon Seroquel Risperdal Fanap Latuda Saphris Abilify Midrin, Amidrin or Isomepthene Sumavel Alsuma Imitrex / Treximet / Zecuity Zomig Amerge Maxalt Axert Frova Relpax DHE-45 Migranal Nasal Spray Ergostat Ergomar Cafergot Methergine Medication List Actiq / Fentora Nucynta Exalgo Demerol or Meperidine Dilaudid or Hydromorphone MSIR, MS Contin, Morphine Sulfate, Avinza, or Kadian Opana Methadone Stadol or Butorphanol Lortab, Lorcet or Hydrocodone Oxycontin, Oxycodone, Xartemis Tylenol III or IV Vicodin or Vicoprofen Fentanyl or Duragesic Patch Butrans Lidoderm Patch / Flector Patches Ultram, Ultracet or Tramadol / Rybix Fioricet / Fiorinal / Dolgic / Orbivan Esgic or Phrenilin Zohydro ER Tylenol Anacin or Excedrin Motrin, Advil or Ibuprofen Anaprox, Aleve, Naprelan, Naprosyn, or Naproxen Sodium Orudis, OruVail or Ketoprofen Arthrotec, Diclofenac, Cambia, or Zipsor Toradol, Ketorolac, or Sprix Lodine or Etodolac Daypro or Oxaprozin Relafen or Nabumetone Feldene or Piroxicam Indocin or Indomethacin Mobic / Meloxican Ansaid / Flurbiprofen Celebrex Pennsaid Voltaren Gel Flector Patch

8 Mid-Atlantic Headache Institute Driving Directions Mid-Atlantic Headache Institute, Inc. Commerce Center West 1777 Reisterstown Road (Route 140), Suite 104 Pikesville, MD From Glen Burnie/Annapolis/Eastern Shore: Take 97 North to 695 West to Exit 20 (route 140) Reisterstown Road. Turn left toward Garrison and bear right. Go to the first traffic light and turn right at Hooks Lane. Turn right at the next light into the Commerce Center complex (you should be looking straight ahead at Ruth Chris Steak House). The office is located to the right in Suite 104, West Building, on the parking lot level. From Delaware/Points North: At 695 from your respective major highways, follow 695 West to Pikesville to Exit 20 (Route 140) Reisterstown Road. Follow the ramp onto Reisterstown Road toward Garrison. Go to the first traffic light and turn right at Hooks Lane. Turn right at the next light into the Commerce Center complex (you should be looking straight ahead at Ruth Chris Steak House). The office is located to the right in Suite 104, West Building, on the parking lot level. From Washington, D.C./Points South: Follow 95 North or 29 North/70 East to 695 towards Towson and follow instructions above for #1. From Carroll County: Take 795 South to 695 towards Pikesville/Towson. Follow directions above for #1.