MRN: T C D PATIENT INFORMATION

Transcription

1 MRN: T C D PATIENT INFORMATION Today s Patient s Date: / / Name: (First) (MI) (Last) Address: City: State: Zip Code: Home #: ( ) - Alternate #: ( ) - Work #: ( ) - Soc Sec #: - - Gender: Male Female Marital Status: Married Single Divorced Widowed Legally Separated Race Language Ethnicity: Hispanic or Latin Not Hispanic or Latin Address: Referring Physician: Primary Care Physician: How did you hear about us? INSURANCE INFORMATION: PRIMARY INSURANCE: Company Policy Number: Group Number: Is the patient the policyholder? Yes Policyholder Information: No Relationship: Male Female Phone Number: ( ) - Employer SECONDARY INSURANCE: Company Policy Number: Group Number: Is the patient the policyholder? Yes Policyholder Information: No Relationship: Male Female Phone Number: ( ) - Employer PARTY RESPONSIBLE FOR PATIENT: Address: City: St: Zip: Relationship Male Female Soc Sec #: - - Home #: ( ) - Alternate #: ( ) - EMERGENCY CONTACT: Phone Number: ( ) - Address: Relationship: City: State: Zip Code: Male Female REVISED 4/28/2017 Macintosh HD:Users:patrickholcombe:Desktop:Tran:NEWPATIENT INFORMATION.doc

2 PREFERRED PHARMACY: Please circle your preferred pharmacy and indicate the pharmacy location. Adams Pharmacy Bay Medical Center Cooper s Pharmacy CVS Kmart Mullins Pharmacy Publix Target Sam s Club St. Andrews Pharmacy Walgreens Wal-Mart Winn Dixie Other: Pharmacy Location: Be specific, Front Beach Road, Back Beach Road, Lynn Haven, 15 th Street, etc. AUTHORIZATION: I authorize Head and Neck Associates of Bay County, P.A. to release medical information or to give a copy of my medical records to my emergency contact and the following people: 1) Phone Number: ( ) - 2) Phone Number: ( ) - Patient or Legal Guardian s Signature: Date: / / ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents. I hereby assign directly to Head and Neck Associates of Bay County, P.A. all benefits, if any, otherwise payable to me for services as described on the attached forms. I understand that I am financially responsible for any and all claim(s) not paid by my insurance company. Patient or Legal Guardian s signature: DATE: / / NOTICE OF PRIVACY PRACTICES My signature below indicates that I have been provided with a copy of the Notice of Privacy Practices. Patient or Legal Guardian s signature: DATE: / /

3 MRN: T C D MEDICAL HISTORY TODAY S PATIENT S DATE: / / NAME: (First) (MI) (Last) REFERRING PHYSICIAN: PRIMARY CARE PHYSICIAN: OCCUPATION: DOB: / / AGE: CHIEF COMPLAINT: HISTORY OF CHIEF COMPLAINT: (onset, duration, modifying factors) 1. **CURRENT MEDICATIONS**: Are you currently taking any medications, including aspirin, vitamins, and herbs? No Yes If yes, please complete the medication list form. Medication Name Milligrams Medication Name Milligrams 2. MEDICAL ILLNESSES: Circle all that apply Stroke Cancer Anemia Hiatal Hernia/ Acid Reflux Kidney Disease Seizure High Blood Pressure Bleeding Disorder Diabetes Arthritis Thyroid Disease Hyperthyroidism Hypothyroidism Goiter Heart Disease Asthma / Bronchitis Hepatitis AIDS/HIV *If Cancer circled, specify type: *Other Illnesses: 3. DRUG ALLERGIES: No Known Drug Allergies Yes, please list all drug allergies: TURN OVER AND COMPLETE BACK OF FORM * Information for Drs to enter, if needed ** Information for Medical Assistants to enter

4 MEDICAL HISTORY continued: 4. SURGICAL HISTORY: Circle all that apply Adenoidectomy / Tonsillectomy Septoplasty Tubes Ears Thyroidectomy / Parathyroidectomy Heart Surgery Hysterectomy Sinus Surgery Not Listed Neck Surgery Not Listed Cosmetic Surgery Healthy-No surgical history *OTHER SURGERIES: 5. FAMILY HISTORY: Circle all that apply M=Maternal (Mother or Mother s side of family) P=Paternal (Father or Father s side of family) CANCER DIABETES HEART DISEASE THYROID DISORDERS Maternal Paternal Maternal Paternal Maternal Paternal Maternal Paternal 6. SOCIAL HISTORY/HABITS: Alcohol Consumption: No Yes, how much? Smoke / Chew Tobacco: No Yes, how much? Age started? Age started? If no, is patient exposed to cigarette smoke? No Yes Do you have any inside dogs or cats? No Yes For patients less than 18 years of age, please answer the following: Does your child attend school? No Yes Does your child attend day care? No Yes Is your child up-to-date on vaccinations? No Yes 7. OTHER FAMILY MEMBERS: Are there other family members who are seen in this practice? No Yes, If yes, please print: * Information for Drs to enter, if needed ** Information for Medical Assistants to enter

5 HEAD AND NECK ASSOCIATES OF BAY COUNTY, P.A. 724 W. 19TH STREET, PANAMA CITY, FL PHONE (850) Quang T. Tran, M.D. Diana L. Barnett, ARNP-C Hans E. Caspary, M.D. Patient Name: Acct # Certain procedures performed in our office are not included in the standard office visit. These procedures will be billed separately and in addition to office visit charges. Some insurance carriers are classifying these procedures as "Surgery" and applying the charges to your surgical deductible, copayment, and/or co-insurance amount. This may result in insurance payment for an office visit but not the procedure. In such cases, payment for the procedure will be partially or completely patient responsibility. Examples of in-office procedures include: Fiberoptic laryngoscopy: This procedure involves passing a long fiberoptic scope either rigid or flexible instrument through the nasal cavity or into the throat. The fiber optic scope enables the physician to visualize areas of the throat not readily seen using the laryngeal mirrors or any other mean. Billing Code Charge Amount $125 Nasal endoscopy: This procedure uses the flexible or rigid scope attached to a light source to view areas of the nasal cavities that cannot be viewed by the physician using the standard nasal speculum or visual inspection. Billing Code Charge Amount $200 Hearing Test: Comprehensive audiometry threshold evaluation and speech recognition Billing Code Charge Amount $63 Tympanogram: is an examination used to test the condition of the middle ear and mobility of the eardrum (tympanic membrane) and the conduction bones by creating variations of air pressure in the ear canal. Billing Code Charge Amount $24 I have read the above information and understand my insurance company may reimburse an in-office procedure as a surgical service with the deductible and co-insurance guidelines applied. I also agree to the financial responsibility established by my insurance carrier according to my individual policy. If you have any question please feel free to speak with our staff and/or contact your insurance carrier for more information. Patient Signature Date Pediatric Otolaryngology Oncology Surgery Disorders of Larynx and Voice Laser Surgery Endoscopic Sinus Surgery Sleep Disorder Surgery Comprehensive Hearing Testing (Adult and Children) Vestibular Evaluation

6 Want to know if Balloon Sinuplasty IS RIGHT FOR YOU? The following questionnaire is intended to help define your symptoms and provide valuable information and insights for your doctor. Answer the questions, rating to the best of your ability the problems you have experienced over the past two weeks. Sino-Nasal Outcome Test (SNOT-22) Patient Name: Patient Phone: Date: 1. Consider how severe the problem is when you experience it and how often it happens, please rate each item below on how bad it is by circling the number that corresponds with how you feel using this scale. 2. Please mark the most important items affecting your health (maximum of 5 items), right column. No problem Very mild problem Mild or slight problem Moderate problem Severe problem Problem as bad as it can be 5 most important items 1. Need to blow nose Nasal Blockage Sneezing Runny nose Cough Post-nasal discharge Thick nasal discharge Ear fullness Dizziness Ear pain Facial pain/pressure Decreased sense of smell/taste Difficulty falling asleep Wake up at night Lack of a good night s sleep Wake up tired Fatigue Reduced productivity Reduced concentration Frustrated/restless/irritable Sad Embarrassed SNOT-20 Copyright 1996 by Jay F. Piccirillo, M.D., Washington University School of Medicine, St. Louis, Missouri SNOT-22 Developed from modification of SNOT-20 by National Comparative Audit of Surgery for Nasal Polyposis and Rhinosinusitis Royal College of Surgeons of England.

7 SINUS RELIEF IS HERE. Balloon Sinuplasty (BSP) is a safe and effective sinus procedure for chronic sinusitis patients seeking relief from uncomfortable sinus pain symptoms. WHAT IS SINUSITIS? Sinusitis is an inflammation of the sinus lining often caused by infections and/or blockage of the sinus openings, altering normal mucus drainage. Frontal sinus SYMPTOMS¹: Nasal obstruction or nasal congestion Thick and discolored drainage Decreased smell or taste Facial pressure, discomfort or fullness Headache Fatigue Bad breath Fever Upper tooth pain Cough Ear pressure Sphenoid sinus Maxillary sinus Sinus Area Close-up HOW DOES BALLOON SINUPLASTY WORK? 1 Step 1: A soft, flexible 2 guidewire is inserted into the blocked sinus. Step 2: The balloon is advanced over the guidewire and is inflated to gently expand the sinus opening. 3 4 Step 3: Fluid is sprayed into the infected sinus to flush out pus and mucus. Step 4: The system is removed, leaving the sinuses open. SAFE - For more information on sinusitis or Balloon Sinuplasty, please visit Inc All rights reserved More than 510,000 patients have been treated by physicians using Balloon Sinuplasty technology.² FAST RECOVERY - While recovery time varies with each patient, many people quickly return to normal activities. 3 PROVEN - Over 70% of patients who have the procedure say they would have it again.³ IN-OFFICE - Available to some patients as a procedure conducted in a doctor s office under local anesthesia Adult Sinusitis. (2016). Retrieved from on August 23, Acclarent Procedural Data Documented on September 1, Karanfilov B, Silvers S, Pasha R. (2013). Office-based balloon sinus dilation: a prospective, multicenter study of 203 patients. Int Forum Allergy Rhinol. 3(5): Balloon Sinuplasty Technology is intended for use by or under the direction of a physician. It has associated risks, including tissue and mucosal trauma, infection, or possible optic injury. Consult your physician for a full discussion of risks and benefits to determine if this procedure is right for you.