ABILENE SURGERY CENTER, LLC. PATIENT INFORMATION FORM Please Print and Provide Complete Information for Each Item

Transcription

1 ABILENE SURGERY CENTER, LLC PATIENT INFORMATION FORM Please Print and Provide Complete Information for Each Item First Name: MI: Last Name: Today s Date Mailing Address: City: County: State: Zip: Primary Telephone: Cell: Date of Birth: _ Age: Sex: Marital Status: Social Security No: Race: White Black Asian Hispanic Non-Hispanic Ethnicity: Caucasian Black Hispanic Other Receive appointment reminders via: TEXT PHONE CALL (You can select up to 3) If you have been seen here before, under what name? Employed: Y N (If yes) Full Time Part Time Self Retired Military Occupation EMERGENCY CONTACT: OTHER THAN SPOUSE FAMILY PHYSICIAN: Phone # Name: Contact s Address: Relationship: Telephone: Is this visit related to an accident or injury? Yes No Date & Type of Injury: Workers Compensation Information: Telephone: RESPONSIBLE PARTY / PARENT / SPOUSE: Name: Occupation: Employer s Address: Social Security No: Relationship: Employer: Telephone: DOB: PRIMARY INSURANCE INFORMATION: Insurance Company: Group Number: Policyholder s Employer and Address: Name of Policy Holder Date of Birth: SS# Policy Number: SUPPLEMENTAL INSURANCE INFORMATION: Insurance Company: Group Number: Relationship to Patient: Self Spouse Child We will need a copy of your insurance cards and driver s license. Name of Policyholder: Date of Birth: SS# Policy Number: Please read and sign below I hereby authorize the physicians and staff of Abilene Surgery Center, LLC to perform procedure as necessary to assess and diagnose my condition properly, and such treatments as may be prescribed by my attending physician during any all visits to ASC, LLC. I understand that I am financially responsible for ALL charges arising from services rendered to me by ASC, LLC. Signature: X Date:

2 Abilene Surgery Center, LLC Release of Information: Abilene Surgery Center, LLC may disclose all or any part of my medical record including verbal information and may provide bills/invoices to: 1) any persons, corporation, agency or their authorized representative who may be liable under a contract to Abilene Surgery Center, LLC, 2) Me or my family members for all or part of the Center s charges including but not limited to: hospital or medical service companies, insurance or third-party payers, worker s compensation or my employer; and 3) any individual or entity designated as a guarantor or party responsible for payment of fees or health care services provided to me. I understand and agree that the information I am authorizing regarding the release of information may include 1) HIV/AIDS test results, diagnosis, treatment and related information; 2) information about drug and alcohol use and treatment, and 3) mental health information. I understand that I may revoke this authorization regarding the release of information at any time, by providing written notice to the Abilene Surgery Center, LLC. except to the extent that action has been taken in reliance on it. Unless earlier revoked, this authorization expires automatically 1 year from the date signed or 1 year after the last clinic visit or after all insurance or third party claims have been paid or satisfactorily resolved, whichever occurs last. Release from Liability: I release and agree to not hold Abilene Surgery Center, LLC, its agent s representatives, and employees liable associated with the release of confidential patient information in accordance with this authorization. I understand Abilene Surgery Center, LLC cannot be responsible for use or re-disclosure of information by third parties. Financial Responsibility and Assignment of Benefits: In consideration for receiving medical or health care services, I hereby assign my right, title and interest in all insurance, Medicare/Medicaid, or other third party payer benefits for medical or health care services otherwise payable to me to Abilene Surgery Center, LLC physicians and/or Medical Practice Income Plan. I also authorize direct payments to be made by Medicare/Medicaid and/or my insurance company or other third-party payer, up to the total amount of my medical and health care charges, to Abilene Surgery Center, LLC Medical Practice Plan. I certify that the information I have provided in connection with any application for payment by third-party payers, including Medicare/Medicaid is correct. I agree to pay all charges for medical and health care services not covered by or exceed the amount estimated to be paid by Medicare/Medicaid, my insurance company, or other third-party payers and agree to make payment as requested by Abilene Surgery Center, LLC. I certify this form has been fully explained to me, that I have read it or had it read to me, and that I understand its contents. Acknowledgement of Patient s Bill of Rights I acknowledge that I have been given the opportunity to receive a copy of the Abilene Surgery Center Patient Bill of Rights as required by Law. Acknowledgement of Receipt of Notice of Privacy Practices Notice to Patient: We are required to provide you with a copy of Notice of Privacy Practices which states how we may use and/or disclose your health information. By signing this form, you acknowledge receipt of the Notice. You may refuse a copy if you wish.

3 Patient Satisfaction Assessment Consideration should be given to assessing patient satisfaction with the ambulatory surgery facility experience. This can be accomplished by telephone or questionnaire. Any quality assurance issues that arise should be addressed in the review of problem cases. Peer Review Consent Forms Surgeons may use a regular hospital s surgery section meeting or an independent review organization. They may also join other surgeons in the geographic area to form their own review group. Another option is an in-house review. Surgeons in a group practice can do this internally. It is permissible for solo practitioners to do in-house review as long as another physician (anesthesiologist, pathologist, etc.) actively participates. Surgeons unable to fulfill the Peer Review requirement by the mechanisms should contact the central office for guidance. There are differences in a legal opinion regarding the need for a consent form giving physicians the authority to peer review a patients chart. Facilities that are part of a doctor s office may not be entitled to protection under state peer review laws if a patient claims invasion of privacy/confidentiality. Therefore, it is an AAAASF standard that peer review permission is obtained from all patients. Although it is recommended that each physician consults an attorney regarding the specific state requirements, below is a sample of a consent form that would meet AAAASF standards: By signing this form, you understand that you are authorizing your physician to disclose complete information concerning his medical findings and treatment of the undersigned, from the initial office visit until the date of the conclusion of such treatment, to those individuals whose sole determination in Abilene Surgery Center, LLC, are required to receive such information for the purpose of medical treatment, medical quality assurance and paper review. Audiovisual Recordings I understand that the procedure may involve the taking and use of still photographs, motion pictures, videotapes, or closed circuit television. Advance Directives: I have signed an Advance Directive Yes No I have provided a signed copy to Abilene Surgery Center, LLC Yes No (In the event of an emergency situation, Abilene Surgery Center would attempt to resuscitate and transfer to the nearest hospital). Patient/ or Authorized Representative Date ASC Witness

4 To Our Patients: Abilene Surgery Center, LLC Disclosure Information Welcome to the practice, which is owned in part by Sunil S. Patel, M.D., PhD and S. Young Lee, M.D. Your Surgeon/Physician: We would like you to know that we have 5 Physicians who practice here in the Abilene Surgery Center, LLC. All Physicians are board certified by the American Board of Ophthalmology and are licensed in the State of Texas. Dr. Patel has been in practice since 1995 and attended UT Southwestern, Presbyterian Hospital, USC/Doheny Eye Institute. Dr. S. Young Lee has been in practice since 2004 in Texas. He attended University of Texas Southwestern Medical School and Baylor College of Medicine. Dr. Grant Janzen has been practicing since 2009 and attended University of Oklahoma College of Medicine, Medical University of South Carolina, Tufts/New England Eye Center and Ophthalmic Consultants of Boston. Dr. Eric Zavaleta has been licensed since 2008 and joined our facility in He attended University of Texas, Texas A&M University, The Methodist Hospital, University of Florida and Retina Specialists of Alabama/ University of Alabama Birmingham. Dr. M. Hammons has been practicing since Dr. Hammons specializes in Oculoplastic. He attended Duke University and Baylor College of Medicine. Dr. Courtney Crawford joined our facility August He served in the Army for 9 years. He completed his training in Vitrectomy surgery at Tufts Medical Center. Dr. Charles L. Clark, III joined our facility in May He attended the University Of Florida Department Of Ophthalmology. Dr. Lynds joined our facility in August Dr. Lynds attended University of Texas Southwestern for his Retina Fellowship as well as Residency. You may request your physicians C. V. (curriculum vitae) which we keep on file. Their training is extensive in the field of Ophthalmology. Should you choose to have surgery at this organization, your physician of choice will be the one performing your surgery unless previous discussions have been conducted with you and the physician. Your Anesthesia Provider: Additionally, this organization utilizes Certified Registered Nurse Anesthetists credentialed anesthesia providers, with many years of experience and training. All of our CRNA s are licensed in the State of Texas. The Team: Our team is made up of competent individuals that will assist in providing safe patient care. You will be cared for by Registered Nurses who have been trained in Ophthalmology and licensed in the state of Texas and Surgical Technicians who assist the physicians and are all trained in Ophthalmic procedures. Should you have a problem/grievance: Please be advised that if you have a grievance or concern the following mechanism exists: Ask for the grievance form from the Front Office Specialist. Or you may call the accrediting organization that oversees our compliance with standards of care, The American Association for Accreditation of Ambulatory Surgery Facilities, Inc or ing info@aaaasf.org. or TMF Health Quality Institute, Review and Compliance, Bridgepoint I, Suite 300, 5918 West Courtyard Drive, Austin, Texas or call or The Texas Department of State Health Services at You may also contact the Office of Medicare Beneficiary Ombudsman at August 7, 2013 Abilene Surgery Center, LLC Revised 04/13/2015; February 01, 2016; rsvd 07/10/2017; rsvd 09/13/2017

5 Abilene Surgery Center, LLC Make a suggestion: If you have a suggestion, please place this in writing and hand to the Front Office Specialist or mail it to the office. Play a part in your care: We encourage all patients to be actively involved in their care, so please speak up and ask questions of anyone in this organization. Please be advised that no punitive or discriminatory action will be taken against you should you choose to exercise your patient s rights. Additionally, please be advised that this organization does not recognize Do Not Resuscitate orders or Living Wills based on organizational conscientious objection which is allowed by: the State of Texas. Abilene Surgery Center, LLC will always attempt to resuscitate a patient and transfer that patient to a hospital in the event of deterioration along with the copy of the advanced directives if available. If desired you, the patient may wish to delegate your right to make informed decisions to another person, even though you are not incapacitated. To the extent permitted by State law, our organization will respect such delegation. If you have any questions, please see the the Front Office Specialist. If you have a living will or other directive that you would like us to keep a copy of please provide us with a copy of that directive. Please inform us if you would like information on Advanced Directives. Infection Control: This practice educates staff upon hire and annually thereafter in hand hygiene and we follow the CDC and APIC guidelines for hand hygiene. We encourage staff to stay home when they are sick. We provide tissues and garbage cans throughout the facility and encourage everyone to cover their mouth when coughing or sneezing and then wash their hands. Should you have a procedure or surgery in this organization we want you to know that we value patient safety. Therefore you may hear us performing certain tasks or asking certain questions that may surprise you. We will ask you identifying information such as your date of birth or your address besides asking you to tell us your name. We take a pause or a time out before we actually start your procedure to assure once again that we have everything that we need and the entire team is in agreement. Only the physician performing your procedure and yourself will mark your surgical site. This organization adheres to strict infection control measures before, during, and after your procedure including but not limited to: procedural technique, the environment of care, care of equipment and instruments, and education of all staff in the most up to date infection control measures. o I have received information regarding the providers of care in this organization, a copy of the Patient s Bill of Rights and Responsibilities, and information regarding the grievance process. Patient/Representative Date: ASC Witness August 7, 2013 Abilene Surgery Center, LLC Revised 04/13/2015; February 01, 2016; rsvd 07/10/2017; rsvd 09/13/2017

6 ABILENE SURGERY CENTER, LLC Disclosure Authorization for Information Requests (Note: This is the form to us for patient s authorization to obtain information from other health car providers). Pursuant to the Health Insurance Portability and Accountability Act (HIPAA), I hereby authorize the following providers: (list all providers from who information is being sought) to disclose the following protected health information to the surgery center. Copies of EKGs and Labs Medical History, including specific progress notes regarding any problems that would impact my surgery or procedure s progress or outcome. Other This protected health information is being used by the facility for the purpose of preparation for an outpatient procedure at the surgery center. I understand that a revocation is not effective to the extent that the center has relied on the use or disclosure of the protected health information. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the receipient and may no loger be protected by federal or state law. (Note: in the event of an Emergency situation, the Leadership of the ASC may be required to disclose or communicate your health care information to other providers and legal entities based (local, state, and federal authorities and guidelines). I understand that the center will not condition my treatment on whether I provide authorization for the requested use or disclosure. >Inspect or copy my protected health information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights). >Refuse to sign the authorization >This authorization for release of records will expire one year from signature date. Patient/or Authorized Representative Date ASC Witness I understand that, as set forth in the center s Privacy Notice, I have the right to revoke this authorization, in writing, at any time by sending written notification to: Abilene Surgery Center Attn: Privacy Officer 5601 Health Center Drive Abilene, Texas Note: You have the right to know specifically what information you are authorizing for release. You have the right to know the names or other identification of the person(s) or organization(s) authorized to release the information. You have the right to know who is going to use it and what it is going to be used for. (You have the right to receive copy of this form).

7 Release of Medical Information: Please provide the names of family members and/or other physicians that Abilene Surgery Center may release medical information to. Patient s release of information will be enforced until revoked in writing by the patient. Name: Relationship: Phone number: Name: Relationship: Phone number: Name: Relationship: Phone number: Name: Relationship: Phone number: Name: Relationship: Phone number: Name: Relationship: Phone number: Patient or Authorized Representative Date ASC Witness Date

8 Abilene Surgery Center, LLC ANESTHESIA HISTORY Name: Age: DOB Height: Weight: List ALL Allergies and Reactions to Medication or Food: ALLERGIES (what you are allergic to) What is the Reaction? List All Surgical Procedures Date Have you had any reactions, allergic or otherwise, to the medications you received in the past during surgical procedures? If so what type of reaction? Is there a family history of allergic reactions and or fevers during anesthesia? Y N Is there a family history of sudden death during General Anesthesia? Y N Do you smoke? Y N If so how much? Do you drink Alcoholic Beverages? Y N If so, how many drinks a week? Are you or could you be pregnant? Y N Date of last menstrual period: Have you had a fever, infection, or taken antibiotics within the last two weeks? Y N *If yes, what antibiotic, when did you start it, and for what reason?

9 Abilene Surgery Center, LLC Please Circle any Health Conditions That You Have Asthma Emphysema Sleep Apnea Chronic Lung Disease High Blood Pressure Heart Attack Angina Artificial Heart Valves Mitral Valve Prolapse Congestive Heart Failure Irregular Heart Beat Swelling of your lower leg Poor Exercise Ability Difficulty Opening Mouth Stomach Ulcer Disease Chronic Acid Reflux Difficulty Swallowing Intestinal Disorders Kidney Disease Liver Disease Glaucoma Easy Bruising/Bleeding Hepatitis B Chronic Pain Stroke Hepatitis C Seizure Disorder Cancer HIV Anemia Muscle Diseases/Disorders Diabetes Type 1 Nerve Injury Thyroid Disease Diabetes Type 2 MRSA (Methicillin Resistance Staff Aureus) Other: Primary Care Physician s Name: Phone# Specialist s Name (example-cardiologist): Phone# Patient Signature: Date: Nurse Signature: Date:

10 Abilene Surgery Center, LLC Name of Pharmacy Address City_ Phone LIST ALL MEDICINES YOU ARE CURRENTLY TAKING: Prescription, over-the-counter medications (examples: Aspirin, Antacids, Tylenol), herbals (examples: Ginseng, ginkgo ) and vitamins. Name of Medication Dosage How Often Taken Today EXAMPLE: Lisinopril 20 MG _ Twice Daily_ Yes NO Patient Signature: Date: Nurse Signature:_Date: