Georgia Northside Ear, Nose, and Throat, LLC

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1 Andrew Diamond, M.D. Craig Richman, M.D. Joshua Downie, M.D. Keith Jackson, M.D. Lora A. Moszczynski, PA-C Jennifer L. Tirino, M.D. Otology and Thomas Chacko, M.D. Allergy : PATIENT INFORMATION Name of Birth Age Social Security # Sex: M F Marital Status: M S D W Address Apt. # City/State/Zip Home Phone Work Phone Cell Phone Address Referring Doctor Doctor s Phone ALTERNATE CONTACT IF PATIENT CANNOT BE REACHED Name Relationship Phone Address Apt. # City/State/Zip Pharmacy Name Phone *** Please notify the office if you change pharmacies. Prescriptions will only be sent to the pharmacy on file. (A) PRIMARY INSURANCE INFORMATION: Please complete regardless of whether or not we have a copy of the card. Insurance Company Name: Address: City/State/Zip: Enter the name of person who is responsible for the primary insurance Cardholder s Name Cardholder s of Birth Relationship to Insured ID # Group # Co-Pay $ Referral: Yes or No Please check: Group Policy or Individual Policy Have you had this policy for longer than 12 months? Yes or No Employer s Name Work Phone PCP PCP Phone (B) SECONDARY INSURANCE INFORMATION: Insurance Company Name: Address: City/State/Zip: Enter the name of person who is responsible for the primary insurance Cardholder s Name Cardholder s of Birth Relationship to Insured ID # Group # Co-Pay $ Referral: Yes or No Please check: Group Policy or Individual Policy Have you had this policy for longer than 12 months? Yes or No Employer s Name Work Phone PCP PCP Phone

2 Andrew Diamond, M.D. Craig Richman, M.D. Joshua Downie, M.D. Keith Jackson, M.D. Lora A. Moszczynski, PA-C Jennifer L. Tirino, M.D. Otology and Thomas Chacko, M.D. Allergy PLEASE READ AND SIGN THE FOLLOWING: CONSENT FOR TREATMENT I hereby consent to and authorize the performance of examinations and treatment for the below named patient that in the judgment of Georgia Northside Ear, Nose, and Throats medical staff may be considered necessary or advisable. Patient s Name CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH CARE INFORMATION I understand that, under the Health Insurance Portability & Accountability Act of 1996, I have certain rights to privacy regarding my protected health information. I understand and consent that this information can and will be used to conduct, plan, and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third-party payers and conduct normal healthcare operations such as quality assessments and physician certifications. I understand that I have the right to review Georgia Northside Ear, Nose, and Throats Notice of Privacy Practices prior to signing this consent. With this consent, Georgia Northside Ear, Nose, and Throats and its employees may, but not limited to, call my home or other alternate locations, leave a message on voice mail or in person, can send mail to my home or an alternate location, in reference to any items that assist the practice in carrying out any treatment, payment or healthcare operations. I may revoke my consent in writing except if the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Georgia Northside Ear, Nose, and Throat may decline to provide treatment to me. Patient s Name

3 Andrew Diamond, M.D. Craig Richman, M.D. Joshua Downie, M.D. Keith Jackson, M.D. Lora A. Moszczynski, PA-C Jennifer L. Tirino, M.D. Otology and Thomas Chacko, M.D. Allergy PLEASE READ AND SIGN THE FOLLOWING: NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I have received, read and understand Georgia Northside Ear, Nose, and Throats Notice of Privacy Practices containing a more complete description of the uses & disclosures of my healthcare information. I understand that Georgia Northside Ear, Nose, and Throat reserves the right to revise its Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by requesting one in person at Georgia Northside Ear, Nose, and Throat 1360 Upper Hembree Rd, Ste 201B Roswell, GA Patient s Name ASSIGNMENT OF BENEFITS I hereby authorize and assign that insurance payments for services provided to me, be made directly to Georgia Northside Ear, Nose, and Throat, LLC Patient s Name FINANCIAL AND PAYMENT POLICY SIGNATURE FORM SIGNATURE FORM SHALL BE HELD AS RECORD OF ACCEPTANCE OF FINANCIAL AND PAYMENT POLICIES I have received and read a copy of Georgia Northside Ear, Nose, and Throat, LLC. Financial and Payment Policy (2 pages). I understand and agree to abide by the policies noted which may be relevant to my financial obligations for services received from Georgia Northside Ear, Nose and Throat, LLC and its employees. I am also aware of my responsibility to provide Georgia Northside Ear, Nose, and Throat, LLC. with accurate and current information, with regards to my insurance coverage, address, and telephone number. Patient Name

4 of Visit: Georgia Northside Ear, Nose, and Throat, LLC Patient Name: of Birth: Age: Height: Weight: Race: Language: Current work status: Employed Occupation: Unemployed Disabled Full-time student Referred for Opinion & Consultation by (Physician s name): REASON FOR TODAY S VISIT: Approximate date of onset: Is the reason for your visit today related to an automobile accident? Yes No of accident: Is the reason for your visit today related to a work injury? Yes No of injury: Have you ever been treated for this problem before? Yes No If yes, please state when and name of treating physician: ALLERGIES Please list any food or drug allergies: MEDICATIONS Please list all medications you are currently taking, including dosages and the physician who prescribes them for you. Name of Medication Dosage and how many times a day Prescribing Physician If there are additional medications, please ask for another page from the receptionist. Please bring an updated medication list to each appointment.

5 Patient Name: of Birth: PAST MEDICAL HISTORY Do you have or have you had any of the following conditions? If yes, please put a check mark. Condition Approximate Onset Treating Physician Cancer (List Type) Heart Disease (Include Heart Murmur, Bypass Surgery, Pacemaker, Mitral Valve Prolapse, Stent, Heart Attack) High Blood Pressure Asthma Liver Disease/ Hepatitis (list type) Jaundice Diabetes Epilepsy/ Seizures/ Neurological Problems Thyroid or Goiter Problems Bowel/ Colon Disease or Problems Bleeding or Clotting Abnormalities An Abnormal Chest X-Ray An Abnormal EKG Stroke Past Injuries or Medical Conditions Treating Physician Past Surgeries Treating Physician Have you ever had complications from surgery or anesthesia? Yes No If yes, please explain: Have you ever received a blood transfusion? Yes No

6 Patient Name: of Birth: FAMILY HISTORY Have any of your direct relatives or immediate family members been treated for the following conditions? If yes, please check off the condition, name their relationship to you and if it was the cause of death. Condition Mother Father Sister Brother Family n/o Arthritis Cause of death/ age Cancer (specify type if known) Diabetes Heart Failure High Blood Pressure Kidney Disease Liver Disease Migraine Obesity Psychiatric Problems Rheumatoid Arthrits Stroke SOCIAL HISTORY Do you use or have you formerly used any of the following products? (Please circle your response.) Alcohol Yes No Non-prescribed drugs Yes No Caffeine Yes No Tobacco Never Current Former Quit : Type: Type: Type: Type: Quantity: Quantity: Quantity: Quantity:

7 Patient Name: of Birth: Are you currently experiencing any of the following symptoms? Please indicate YES or NO Yes No Symptom Yes No Symptom Yes No Symptom CONSTITUTIONAL GASTROINTESTINAL NEURO/PSYCHIATRIC Chills/rigors Abdominal pain Focal weakness Fatigue Blood in stool Headache Fever Constipation Memory impairment Night sweats Diarrhea Seizures Weight loss Fecal incontinence Speech changes Change in appetite Difficulty swallowing Tremors Nausea Vertigo HEENT Vomiting Visual changes Vertigo Weight loss Incoordination Ear infections Black, tarry bowel Severe depression movements Nasal drainage Jaundice Sinus problems Heartburn DERMATOLOGIC Throat pain/ Hoarseness Contact allergy: Eye pain GENITOURINARY Change in mole Facial pain Cloudy urine Skin lesion: Foul urine odor RESPIRATORY Painful urination MUSCULOSKELETAL Cough Frequent urination Back pain Wheezing Bloody urine Bone/joint symptoms Snoring Urinary incontinence Myalgia Shortness of breath Passage stone/gravel Neck stiffness/ pain Frequent upper respiratory infections Rheumatologic manifestations REPRODUCTIVE Muscle weakness CARDIOVASCULAR Pain in the breasts Chest pain History of infertility HEMATOLOGIC Irregular heartbeat/ Postmenopausal Easy bleeding Palpitations Age: Year: Syncope/ Fainting Hormone replacement therapy Easy bruising VASCULAR ENDOCRINE IMMUNOLOGICAL Leg pain with exercise Chronically overweight Hay fever Edema/ Swelling Chronically Hives underweight Redness of legs Cold intolerance Asthma Varicose veins Generalized weakness Food allergies Paresthesias/ Pins & Goiter Environmental allergies Needles sensation Excessive thirst

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please