Patient Name DOB Sex M F

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Patient Name DOB Sex M F Social Security Ethnicity Marital Status Address City/State/Zip Email Race Preferred Language Employer Please check one box to indicate preferred number Home Phone Cell Phone

1 Patient Name DOB Sex M F Social Security Ethnicity Marital Status Address City/State/Zip Race Preferred Language Employer Please check one box to indicate preferred number Home Phone Cell Phone Emergency Contact & Phone Work Phone Primary Care/Pediatrician/Referring Physician(Provider that requested you see Ohio ENT & Allergy Physicians- Sleep Division) Name Practice Name Address City/State/Zip Parent/Guarantor Information Please complete for all responsible parties Phone Fax n Name Relationship to Patient Name Relationship to Patient Social Security DOB Social Security DOB Address City/State/Zip Home Phone Work Phone Address City/State/Zip Home Phone Work Phone Can you receive calls at work? Yes No Can you receive calls at work? Yes No May we leave you a voice mail? Yes No May we leave you a voice mail? Yes No Occupation Employer Insurance Information Insurance Name ID/Group Subscriber Name Subscriber DOB Relationship to patient Occupation Employer Secondary Name ID/Group Subscriber Name Subscriber DOB Relationship to patient n

2 Name: Patient Medications DOB: Preferred Pharmacy: Pharmacy Phone: Pharmacy Address: I am not currently taking any medications (including over the counters, herbals, etc) Route Medication Name (i.e. oral, etc) Dose/Strength Frequency Taken Reason for taking Patient Medication Allergies Are you allergic to latex? Yes No Are you allergic to medical tape? Yes No Do you have any know drug allergies? Yes No If Yes please list all medications you are allergic to below Medication Name Reaction Stop: Sections below to be completed by office staff Reviewed by Review Reviewed by Review

3 Name: Past Medical History DOB: Anemia Diabetes Type 1 Heart Attack/MI Anesthesia Complications Diabetes Type 2 Osteoarthritis Angina Pectoris Endocarditis Osteoporosis Anxiety GI Bleed Polio Asthma GERD Pulmonary Embolism Atrial Fibrillation Hayfever/Allergies Seizure Disorder Atrial Flutter Hemochromatosis Spinal Cord Injury to back Autoimmune disorder Hepatitis A Spinal Cord Injury to neck Bleeding disorder Hepatitis B Stroke/TIA Blood Transfusions Hepatitis C SVT Brain Tumor HIV Syncope Cancer Hyperlipidemia Thyroid disorder Cerebrovascular Disease Hypertension Tuberculosis Cirrhosis Hypothyroidism UTI-Recurrent Concussion Hyperthyroidism Valvular Heart Disease Congestive Heart Failure Impotence Ventricular Tachycardia COPD Kidney Disease Coronary Heart disease Kidney Stone CRF Liver Disease Past Surgical History Unremarkable Adenoidectomy Aortic Valve Replacement Bronchoscopy CABG Carotid Endarterectomy Carpal Tunnel Cataract Extraction Craniotomy Gastric Bypass Hip Replacement Interventional pain procedures Mitral Valve Replacement Septoplasty Sinus Surgery Tonsillectomy UPPP Uvulectomy

4 Name: DOB: Family History History Unknown or Adopted Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Allergies Diabetes Cancer & Type Bleeding disorder Heart problems Thyroid problems Arthritis Stroke Anesthesia problems Sleep Apnea Narcolepsy Insomnia Restless Leg Syndrome Social History Current smoker Alcohol use Former smoker Never smoked Drug use Pediatric Patients Clinical Staff Signature Exposure to smoke Attends Day Care Smokeless tobacco Caffeine use Pets in home Physician Signature Chocolate

5 Name: DOB: Review of Systems Please indicate either YES or NO if you are currently experiencing the following symptoms: Yes No Yes No Yes No General HEENT HEME Fever Vision issues Enlarged Lymph Nodes Malaise Discharge/Tearing Yes No Yes No Ringing in Ears Oropharynx/Throat Allergy Hearing Loss Throat dryness/itching Allergies Vertigo Throat Clearing Yes No Earache Tonsil Stones Neurologic Nasal Congestion/Discharge Recurring Strep Throat Memory issues Post Nasal Drip Sore Throat/Pain Concentration issues Sneezing Hoarseness Headache Sinus Pressure/Pain Difficulty Swallowing Numbness Nasal Bleeding Lump in Neck Weakness Nasal Obstruction Mouth Breathing Double Vision Loss of Sense of Smell Snoring/Apnea Yes No Yes No Yes No Pulmonary GI Psychiatric Wheezing Nausea/Vomiting Depression Asthma Anxiety Cough Hallucinations ADHD Staff Use Only Chief Complaint: Height: Weight: Temp: Referring Physician: Clinical Staff Signature Physician Signature

6 Medication History Consent I authorize Ohio ENT & Allergy Physicians- Sleep Division to gather my electronic medication history view via my pharmacy records and my insurance benefit management company records. or I decline: Assignment of Benefits I acknowledge financial responsibility for all facility and physician/provider fees. I understand that the physician billing office will file my insurance claim and I assign direct payment to the physician for all payments made under the terms and provisions of my policy. I further understand that any disputes on coverage are between my insurance carriers and myself and I will be responsible for payment for denied services regardless of the outcome of my dispute. I acknowledge financial responsibility for all charges if inaccurate insurance information is given at time of service and the information is not corrected prior to my insurance s timely filing limit. Receipt of Notice of Privacy Practices I have received the practice s Notice of Privacy. Photocopies of this document are to be as valid as the original. Telephone Consumer Protection Act I authorize Ohio ENT & Allergy Physicians- Sleep Division and any entity authorized by Ohio ENT & Allergy Physicians- Sleep Division including those using automated dialing systems, automated messages, , text messaging or other electronic communications to contact me for any reason by using any telephone number, or mailing address I provide. or I decline: Communication Preferences Regarding Protected Health Information To assist in your care it may be necessary to release Protected Health Information (PHI) to someone other than yourself. To whom may we speak about your care? Please list names to right of relationship. Yes No Spouse Parent/Step Parent Caregiver Other May we leave a message on: Yes No Your answering machine/voic at home Your answering machine/voic at work Patient Name Patient or Representative Signature

7 Medicare Assignment of Benefits I request that payment of authorized Medicare benefits be paid to University Otolaryngologists Inc dba Ohio ENT an Allergy Physicians for any services furnished to me by one of their physicians or other medical providers. I authorize release to the Centers for Medicare and Medicaid Services and its agents any medical information about me necessary to determine payments for related services. This authorization shall remain in effect for my lifetime or until I choose to revoke it. Print Medicare Beneficiary Name Medicare Identification Number Signature of Medicare Beneficiary

8 Appointment Cancellation and No Show Policy Ohio ENT & Allergy Physicians- Sleep Division is privileged to provide medical and surgical treatment to our patients. We work diligently to maintain a high level of personalized service and strive to accommodate patient needs for office visits in a timely manner. This requires careful planning and coordination among many individuals in our office. We understand that emergencies arise from time to time for you, our patient, just as they do for us. However when a patient cancels an appointment without adequate notice or fails to keep an appointment we cannot use that time to service the needs of other patients. We respectfully request your understanding and agreement to our policy as it is stated below. New Patients We will give you a reminder call 48 hours in advance of your scheduled appointment. Any new patients who fails to keep an appointment or who cancels or reschedules an appointment less than 24 hours prior to the appointment will be required to pay a fee of $35.00 in order to schedule a new office visit. For Monday appointments cancellations must be made by noon on the proceeding Friday. This fee must be paid prior to your next appointment. Established Patients Any established patient who fails to keep an appointment or who cancels or reschedules an appointment less than 24 hours in advance will be charged a fee of $20.00 per occurrence. For Monday appointments cancellations must be made by noon on the proceeding Friday. If an established patient fails to keep three appointments, or fails to give adequate notice on three occasions, the practice has the right to dismiss that patient. Fees All fees charges by Ohio ENT & Allergy Physicians- Sleep Division pursuant to this policy are not payable by your insurance company. All fees are payable on or before your next visit or within 30 days of receipt of a billing statement for the fee, whichever is earlier. Your physician may waive your fee for good cause. To request your fee be waived you must a written explanation to: nsappeal@ohpin.com Please enter your physician s name in the subject line of the . If you do not have access you may write a letter to N/S appears, 1810 Mackenzie Dr, #2, Columbus OH Patient Signature

Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country

Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country Hoover Hearing Clinic A division of Hoover ENT Hoover, Alabama 35244 205-733-9694 Tel PATIENT INFORMATION ACCOUNT # DATE MD NEW UPDATE Patient s Full Name DOB Age Patient s SSN Sex: Male Female Preferred