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new patient forms - New Patient Medical History

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new patient forms - New Patient Medical History

  1. 1. WELCOME TO BROWNSBORO CARDIOLOGY STEVEN FILARDO, M.D. SYED RAZA, M.D. PATIENT INFORMATION Date: ______/______/______ Patient Name: _________________________________ Date of Birth: ______/______/______ Address: _________________________________________________________________________ Street City State Zip Code Home Phone#: ( ) Cell#: ( ) Social Security Number: Sex: Female Male Employer: Work Phone#: ( ) Marital Status: Single Married Divorced Widowed If married, spouse’s name: ______________________________________________________ Spouse’s employer: ___________________________________________________________ Do you have a Living Will? Yes No Do you have a Power of Attorney? Yes No If yes, who? _________________________________________________________________ Emergency Contact: _______________________________ Relationship: __________________ Home# :( ) Cell# :( ) Work# :( ) INSURANCE INFORMATION Primary Insurance Secondary Insurance Subscriber Subscriber Policy Number Policy Number Group Number Group Number Insured’s DOB Insured’s DOB PHYSICIAN(S) INFORMATION Referring Physician: _______________________________ Phone# :( ) Primary Care Physician: _____________________________ Phone# :( ) Other Physicians involved in your care: _____________________________________________________ _____________________________________________________________________________________ Pharmacy Name: _____________________________ Phone Number ( )__________________
  2. 2. NEW PATIENT MEDICAL HISTORY Patient: _________________________________________ Date of Birth: _____________ Medical History: Check box if you have ever had any of the following:  Asthma  Gallstones  Stroke  Angina/Chest Pain  Heart Attack  Thrombophlebitis  Anemia  Heart Murmur  Thyroid Disease  Arthritis  Headaches  Tuberculosis  Glaucoma  Hepatitis  Ulcers  Cancer  High Blood Pressure  Other – Please List Below  Chronic Bronchitis  High Cholesterol  Cirrhosis  HIV positive/AIDS  Clotting Disorder  Kidney Disease  Diabetes  Kidney Stones  Emphysema  Migraines  Epilepsy  Positive TB Test  Fractures  Rheumatic Fever Family History: If any blood relativehas ever had any of the following,please check box and indicaterelationship. Pleaseindicatethe age and either L or D for each of the following: Age L = Living D = Deceased  Bleeding Tendency Father  Cancer Mother  Diabetes Siblings  Heart Attack  Heart Disease  High Blood Pressure  Kidney Disease  Liver Disease  Migraine Headaches  Stroke  Tuberculosis Operations and/or Hospitalizations: List below with approximate date: Reason Date Reason Date Allergies to Medications: ________________________________________________________ _____________________________________________________________________________________
  3. 3. Review of Symptoms Check box if you have any of the following symptoms: Respiratory Cardiology General  shortness of breath  chest pain  weight gain  congestion  palpitations  weight loss  cough  varicose veins  loss of appetite  short of breath on exertion  sweating  fevers  swelling  weakness Endocrine  fluttering sensation  fatigue  cold intolerance  heat intolerance Ophthalmology  increased thirst Gastroenterology  nausea  heartburn  constipation  diarrhea  difficulty swallowing  indigestion  abdominal pain Urology  frequent urination  difficult or painful urination  blood in urine Female Reproductive  pregnant  menopause Male Reproductive  difficulty with erection Hematology  easy bruising  bleeding Psychology  depression  anxiety  high stress  diminished vision  blurring of vision  loss of vision  vision floaters Neurology  headaches  tingling  fainting  dizziness  difficulty walking  memory loss Musculoskeletal  joint pain  leg cramps Dermatology  rash  flushing  wound  dry skin  back pain  arm pain  neck pain  leg pain  muscle pain Habits  Smoking Packs Daily? ______  Coffee: Cups Daily _________ Sleep: Snoring Y N How Long? _______ Other Caffeine : ____________ Daytime Drowsiness Y N Interested in stopping? Y N  Alcohol: Type ____________ Difficulty Falling Asleep Y N If you quit, when did you quit? Frequency ________ Continuity Disturbances Y N ___________________________ Amount __________ Early Morning AwakeningY N How long did you smoke?  Diet: Salt Intake ________ Other _______________________ ____________________________ Fat Intake ________ ____________________________ Do you exercise routinely? Y N What do you do for exercise? _____________________________ Have you ever used illegal drugs? Y N If so, what drugs? ______________________________
  4. 4. MEDICAL INFORMATION AUTHORIZATION Patient Name ____________________________________ Date of Birth ______/______/______ I authorize the personnel of Dr. Steven Filardo & Dr. Syed Raza to release all medical information to my family members and friends listed below. I may revoke this authorization by phone or in writing at any time. Name Relationship to patient Phone Number(s) 1 2 3 4 5 6 7 8 9 10 Permission to leave a message on an answering machine or voice mail  Yes  No __________________________________________________ _______/_______/_____ Patient Signature Today’s Date __________________________________________________ _______/_______/_____ Witness signature (other than family) Today’s Date
  5. 5. Brownsboro Cardiology 9501–A Norton Commons Blvd Prospect, KY 40059 (502) 262-7221 Acknowledgement of Receipt of Privacy Notice I have received the Brownsboro Cardiology Notice of Privacy Practices. I understand that my protected health information may be used as described in the notice. _______________________________________________ _____/______/_____ Patient Name Date of Birth _______________________________________________ _____/_____/______ Patient Signature Today’s Date Electronic Prescriptions In order to comply with new government guidelines, we will be submitting prescriptions electronically to pharmacies as much as possible. This will be of tremendous benefit to everyone involved. This will not only ensure proper medications and dosages are submitted to the pharmacy, but will also decrease the number of lost prescriptions and medication errors. Any prescription data transmitted will be used only for the express purpose of prescription filling and submission of the necessary codes to the insurer for payment. I understand purpose of electronic prescriptions and agree that my prescriptions may be transmitted electronically. ___________________________________________ _____/______/_____ Signature Today’s Date
  6. 6. Authorization and Release for All Patients I permit a copy of this authorization to be used in place of the original. I understand that:  Billing for Brownsboro Cardiology will be processed through Steven D. Filardo, M.D. of Preferred Cardiology of Kentuckiana or from Syed Raza, M.D. of Kentuckiana Heart Doctors.  As the patient, I am responsible for the bill, regardless of any insurance coverage, and that all balances are due upon receipt of the bill.  If I have an office visit co-pay, it is due at the time of the service.  I will be charged a $25.00 returned check fee if my bank returns my check to Preferred Cardiology of Kentuckiana or Kentuckiana Heart Doctors.  I will be charged a $25.00 for a missed office appointment, $35.00 for a missed echocardiogram, and $100.00 for a missed stress test if not cancelled 24 hours in advance. If I repeatedly fail to show for or cancel appointments, I may be asked to find another physician. Preferred Cardiology of Kentuckiana and Kentuckiana Heart Doctors are required to pay in advance for the technician and medication used for these tests. I authorize:  Use of this form on all my insurance submissions and release of information to my insurance company(ies).  The doctor to act as my agent in helping to obtain payment from my insurance company(ies).  Release of protected health information regarding services rendered by physicians and employees of Preferred Cardiology of Kentuckiana or Kentuckiana Heart Doctors. If my insurance company requires an authorization to be seen by or have services performed by the physician, I understand that is my responsibility to obtain this authorization from the insurance company. It is not the responsibility of Preferred Cardiology of Kentuckiana or Kentuckiana Heart Doctors or the hospital to obtain the authorization from the insurance company. If payment is denied by my insurance company because of my failure to obtain this authorization, I am financially responsible for payment. In the event that my account is turned over to collections for non-payment, I understand that in addition to the balance of my account, I am responsible for the cost of placing my account with the collection agency, plus any and all court costs that may ensue. Additional Authorization only for Medicare Patients: I request that payment of authorized Medicare benefits are made to Preferred Cardiology of Kentuckiana or Kentuckiana Heart Doctors for any services furnished me by that physician or supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable and related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in Item 9 of the HCFA-1500 form, elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes release of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and the non-covered services. Coinsurance and the deductibles are based upon the charge determination of the Medicare Carrier. X__________________________________ ___________________________ _____/______/_____ Signature of Patient Printed Patient Name Date Signed