Chandler Family Care 6245 W. Chandler Blvd. #E-4 Chandler, AZ (Phone) (Fax)

Transcription

1 Chandler Family Care 6245 W. Chandler Blvd. #E-4 Chandler, AZ (Phone) (Fax) I hereby give my consent for Chandler Family Care to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Chandler Family Care s notice of Privacy Practices provided a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing of this consent. Chandler Family Care reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Chandler Family Care at 6245 W. Chandler Blvd #E4, Chandler AZ, With this consent, Chandler Family Care may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others. With this consent, Chandler Family Care may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder card and patient statements. With this consent, Chandler Family Care may to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Chandler Family Care restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if is does, it is bound by this agreement. By signing this form, I am consenting to Chandler Family Care s, use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Chandler Family Care may decline to provide treatment to me. Signature of Patient or Legal Guardian Patient s Name Date Printed Name of Patient or Legal Guardian

2 CHANDLER FAMILY CARE A Harold Meyerowitz M.D W. Chandler Blvd., Suite #E4, Chandler, Arizona Patient Demographics Original: Update: NAME: SOCIAL SECURITY# Last First MI ADDRESS: STATE ZIP: No & Street Apt No City HOME CELL WORK PHONE: PHONE: PHONE: Ext. ADDRESS: BIRTH DATE: SEX: M F Single Married Widowed Divorced ETHNICITY: Hispanic Non-Hispanic Not specified PREFERRED LANGUAGE: English Spanish Other RACE: African American or African Asian American or Asian Caucasian or European American Native American or Native Alaskan Native Hawaiian or other Pacific Islander Other Race Do you smoke? Yes No If so, how often? PRIMARY No Insurance INSURANCE CO POLICY/ID# GROUP # SUBSCRIBER Name DOB Social Security Number Relationship to Patient EFFECTIVE DATE SECONDARY No Secondary Insurance INSURANCE CO POLICY/ID# GROUP # SUBSCRIBER Name DOB Social Security Number Relationship to Patient EFFECTIVE DATE RESPONSIBLE PARTY: Self NAME: SECURITY# Last First MI ADDRESS: STATE ZIP: No & Street Apt No City HOME CELL WORK PHONE: PHONE: PHONE: Ext

3 CHANDLER FAMILY CARE A Harold Meyerowitz M.D W. Chandler Blvd., Suite #E4, Chandler, Arizona EMERGENCY CONTACT: Name Relationship Contact Number You may share my health information with: None Name: Birth Date: Relationship Last First Name: Birth Date: Relationship Last First Name: Birth Date: Relationship Last First I, the undersigned, authorize and request payment of medical benefits be made directly to A. H. Meyerowitz, M.D., of Chandler Family Care, for any medical or surgical services and supplies furnished me by the physician or by persons under his supervision. I understand that I am financially responsible for any amount not covered by my insurance carrier(s) and agree to make such payment within 60 days. I also authorize you to release to my insurance company or their agent information concerning health care, advice, treatment, and/or supplies provided to me. This information will be used for the purpose of evaluating and administering claims for benefits or for further medical care. I certify that the information given by me in applying for payment of claims is correct. A photocopy of this authorization is as valid as the original. I have received a copy of Welcome to Chandler Family Care. Chandler Family Care does not accept third party insurance such as workers comp or auto insurance. PATIENT SIGNATURE DATE SIGNED

4 Chandler Family Care A. Harold Meyerowitz M.D W. Chandler Blvd., Suite E4, Chandler, Arizona FINANCIAL POLICY Thank you for choosing Chandler Family Care for your health care needs. We are committed to your treatment being successful and to a longterm commitment with you. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy. **Please review and initial next to each section** Things to bring with you to EACH appointment: Health Insurance Card(s) Drivers License Method of Payment A current list of ALL medications Appointments: You MUST arrive for your appointment 10 minutes early or you will be asked to reschedule. Please inform the receptionist of any demographic changes (phone number, address, insurance information, etc). Failure to notify us immediately of changes in demographic information, financial status and/or insurance coverage may result in you being responsible for any services not covered by your insurance carrier. It is your responsibility to verify that the physician is currently under contract with your insurance plan and that you have obtained all necessary referrals BEFORE your scheduled appointment. (Failure to confirm this may result in your responsibility for any and all charges.) Missed or Cancelled Appointments. 24 hours notice is required to cancel and/or reschedule all appointments. Failure to do so will result in a $25 fee charged to the patient. All fees are required to be paid BEFORE your next appointment. Insurance It is the patient s responsibility to understand their insurance coverage. Your insurance coverage and benefits are a contract between you and your insurance company and therefore all disputes must be handled between you and your insurance company. We are required to file with your primary insurance carrier only. It is your responsibility to file charges with any secondary insurance carriers for reimbursement. Payments due at the time services are rendered: Co-pays and all non-covered services are the insured/patient s financial responsibility and are due during the check-in process. Failure to produce payment may result in your appointment being rescheduled. Past due balance s are required to be paid prior to any further services provided by our office unless other arrangements have been made with our Patient Accounts Department. Disability/FMLA forms and Medical Records Filling out Disability/FMLA forms will incur a fee of $ If additional forms are requested a fee of $30.00 will incur each time a form is completed. Letters requested by patients will incur a fee of $40.00 per letter. Copying of medical records will incur the following fees: $75.00 flat rate. These fees are the responsibility of the patient. Upon receipt of payment, forms will be returned within 10 business days. Lab/ Hospital Charges: Any service(s) provided by a lab or hospital is a contract between you and that lab or hospital. Any dispute with that lab or hospital should be handled with that lab or hospital and is not the responsibility of our practice. It is your responsibility to know which services your insurance will and will not cover at these facilities. Payment Plans: If you need to work out payments with our office, please contact our Office Manager. Allow 5 mail days prior to each due date for each payment to be received by our practice. Collections and Outstanding Balances: Delinquent accounts may be placed with a collection agency. Any balances past due 90 days or more will be turned over to collections unless arrangements have been made with the Office Manager. In the event that your unpaid balance is turned over to a collection agency for recovery, collection and attorney fees will be added to your balance. Returned checks will incur a $25.00 service fee. All fees are required to be paid BEFORE your next appointment. Please sign below to confirm that you have read and understand the Financial Policy that has been provided by Chandler Family Care Signature Patient Today's date Date of Birth

5 Name ALLERGIES (INCLUDING REACTIONS TO MEDICATIONS) Date of Birth Other Allergies: List ALL Current Medication Over the Counter Medications: Cold or cough Aspirin or other pain reliever Antacid Sleeping pills Laxatives Allergy Relief medicine Eye Drops Vitamins (type) Herbals and supplements Other: YES NO Have you had any of the following illnesses? Measles Chicken Pox Whooping Cough Mumps Scarlet Fever Rheumatic Fever Pneumonia Infectious Mononucleosis Malaria Tuberculosis Asthma Hay Fever Dysentery/Amoebae in stool Cancer Thyroid Disease Anemia/Bleed Tendency Epilepsy/Seizures Mental or nervous disorder Do you perspire excessively? Do you suffer frequent headaches? Do you have severe headaches or migraines? Do you faint easily? Have you even been knocked unconscious Do you have lightheadedness/dizziness?

6 Name Date of Birth AGE Living (Give Health) Have any of your immediately family had the Decease (Give Cause) following Mother Yes No Tuberculosis Father Diabetes (Sugar in Urine) Sister(S) Cancer Thyroid Disease Brother(S) Heart Disease High Blood Pressure Spouse Asthma and Hay Fever Children Anemia/Bleeding Tendency Mental Nervous Disorders Epilepsy/Seizure FAMILY MEDICAL CONDTIONS: Check all that apply: Gallstones Pancreatitis Peptic ulcer disease Hepatitis Irritable bowel syndrome Reflux, GERD Angina Heart attack Congestive Heart Failure Mitral valve prolapsed Atrial fibrillation High blood pressure Stroke Asthma COPD; Emphysema Sleep Apnea Diabetes Mellitus Chronic renal failure Kidney stones Seizure Chronic fatigue syndrome Fibromyalgia Rheumatoid arthritis Osteoporosis Glaucoma Depression Bipolar disorder Cancer: Breast Skin Prostate Colon Other Other medical problems not listed above: SURGERY/ HOSPITALIZATIONS, AND/OR OUTPATIENT PROCEDURES: LIST ALL IMPORTANT ILLNESS IN THE PAST FIVE YEARS Alcohol Y / N Smoke Y / N Packs Per Day yrs. Immunizations DPT Polio MMR Tetanus (dt) Cocci Skin Test TB Skin Test Influenza Pneumovax DATES (IF KNOWN)

7 OTHER HEALTHCARE PROFESSIONALS Date of Birth: Please Complete the Following List. If you do NOT have a Specialist in an area please mark None Previous Primary Care Physician: Address: Phone Number: Fax: Allergist None Cardiologist None Dentist None Dermatologist None Endocrinologist None Gastroenterologist None Gynecologist None Hematologist/Oncologist None Neurologist None Orthopedist None Pain Medicine None Podiatrist None Pulmonologist None Rheumatologist None Sleep Medicine None Sports Medicine None Nephrologists None Other Previous Physicians Urologist None Address: Phone Number: Fax: Specialty:

8 Chandler Family Care Dr. Arnold H. Meyerowitz 6245 W Chandler Blvd Ste E4 Chandler AZ Phone: Fax: Authorization to Release Information to Chandler Family Care (CFC) I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange): of All my medical records; also educational records and other information related to my ability to perform tasks. This included specific permission to release: All records and other information regarding my treatment, hospitalization, and outpatient care including and not limited to: o Psychological, psychiatric or other mental impairment(s) o Drug abuse, alcoholism, or other substances abuse o Sickle cell anemia o Records which may indicate the presences of communicable or venereal disease which may include, but are not limited to, disease such as hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus, AIDS and tests for HIV FROM WHOM: All medical sources (hospitals, clinics, labs, physicians, psychologist, etc.) including mental health, correctional addiction treatment, and VA health care facilities. TO WHOM: Chandler Family Care PURPOSE: Continuity of Care DURATION: This authorization shall become effective immediately and shall remain in effect for 1 year from the date of signature if no date entered. REVOCATION: This authorization may be revoked in writing by the undersigned at any time prior to the release of information from the disclosing party. Written revocation will not affect any action taken in reliance on this authorization before the written revocation was received. Patient Information Name Date of Birth Address City State Zip Code Phone Signature of Patient Date