Prescription refills should be called in 24 hours before needing them. No refills will be made on weekends or holidays.

Transcription

1 TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A. Dr. Samer H. Fahoum Dr. R. Roger Gleason, III Dr. John W. Hollingsworth, II Dr. Obinna I. Okoye Dr. John T. Pender, Jr Fairmount Avenue Fort Worth, Texas Phone 817/ Fax 817/ TO OUR NEW PATIENTS You have been scheduled to see one of our physicians. If you have seen any of our physicians in the past, please call our office immediately and let us know. Please complete all of the enclosed information and bring it to your appointment, along with your insurance cards and driver's license. Please plan to arrive 15 minutes prior to your appointment. If you are unable to keep your appointment, please call our office as soon as possible, as this will allow us to schedule another patient in that time slot. If you do not cancel your appointment at least 24 hours in advance, you may be charged for your visit. NOTE: If your insurance company is an HMO, Managed Care, or POS and requires a referral, it is the responsibility of your primary care physician to obtain the initial referral. If you do not have your referral at the time of your appointment, you will be rescheduled and/or responsible for the bill. You must bring all chest x-rays and CT scans (on CD/DVD) of your chest (with reports) to your appointment. If you fail to bring these, you may be rescheduled. We also ask that you bring all current medications with you to your appointment. Office visit fees, including tests, range from $100 to $600 and new patient appointments last approximately one hour. Insurance copayment and any deductibles are required at the time of service. If you feel you have special circumstances that prevent you from paying at the time of service, contact our office BEFORE your appointment. Our physicians employ registered nurses who are specifically trained to handle your questions by telephone. This helps increase the availability of medical advice without increasing the cost to our patients. Your physician will call you personally if there is a question only he can resolve. The best time to call is between 8:30 and 10:30 a.m. The nurse will return your call as soon as possible. However, often it is in the afternoon before the nurse returns your call. We make every effort to return your call the same day it is placed. If you are experiencing an acute breathing emergency, please inform the receptionist at the time of your call. Prescription refills should be called in 24 hours before needing them. No refills will be made on weekends or holidays. Free parking is available in our adjacent lot. In addition, we have wheelchairs and back-up E-cylinders for oxygen in case of an emergency. ***FOR YOUR INFORMATION*** Appointment Time: Appointment Date: Your Doctor is:

2 TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A Fairmount Avenue Fort Worth, TX DIRECTIONS: Heading North/Southbound on I-35W, take the W Rosedale Street exit. Head west on Rosedale. Drive approximately 18 blocks. You cannot turn left on Fairmount from Rosedale going west. Either turn left on 6 th Avenue, then right on W Oleander Street, or make a U-turn on 8th Avenue and turn right on Fairmount. Park in the lot at the northeast corner of W Oleander Street and Fairmount, just north of our building. East/Westbound I-30, exit Summit/8 th Avenue. Turn south on Summit. (Summit becomes 8 th Avenue.) Turn left on W Rosedale Street. Turn right on Fairmount Avenue. Park in the lot at the northeast corner of W Oleander Street and Fairmount, just north of our building.

3 TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A. Instructions for Pulmonary Function Testing Do not use inhalers or nebulizer medication for four hours prior to your breathing test. If you experience severe shortness of breath and feel you need to use your medication, do so and call the office. Please ask to speak with the staff in the Pulmonary Function Lab to inform them of your medication use. Do not drink any carbonated beverages or ingest caffeinated food or drink for at least three hours prior to testing. Avoid eating a heavy meal two hours before testing. Do not smoke for at least three hours prior to the breathing test. Do not drink alcohol for at least four hours before the test. Do not exercise 30 minutes before the test. Wear loose, comfortable clothing that does not restrict your breathing. Please inform the technician prior to testing if you have hearing loss or will need an interpreter on the day of your breathing test. If you are not fluent in English, please bring a translator with you on the day of the test. If you wear dentures, you will be asked to remove them during the test. If you experience any chest pain, pressure, discomfort or severe shortness of breath on the day of your test, please contact our office and ask to speak with the staff in the Pulmonary Function Lab. Your test may be canceled or delayed due to these symptoms or may be performed with the physician s consent. We do not allow children in the Pulmonary Function Lab. Please make arrangements for the care of your children while you are away. You will be asked to empty your bladder before the procedure to optimize comfort. If you have any questions, please call our office at and ask to speak with the staff in the Pulmonary Function Lab. Patient Name: Testing Date and Time:

4 TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A. Your Pulmonary Function Testing is scheduled at the location selected below: 1201 Fairmount Avenue Fort Worth, TX DIRECTIONS: Heading North/Southbound on I-35W, take the W Rosedale Street exit. Head west on Rosedale. Drive approximately 18 blocks. You cannot turn left on Fairmount from Rosedale going west. Either turn left on 6 th Avenue, then right on W Oleander Street, or make a U-turn on 8 th Avenue and turn right on Fairmount. Park in the lot at the northeast corner of W Oleander Street and Fairmount, just north of our building. East/Westbound I-30, exit Summit/8 th Avenue. Turn south on Summit. (Summit becomes 8 th Avenue.) Turn left on W Rosedale Street. Turn right on Fairmount Avenue. Park in the lot at the northeast corner of W Oleander Street and Fairmount, just north of our building Booth Calloway, Suite 402 North Richland Hills, TX DIRECTIONS: Major crossroads are Booth Calloway Road and West Pipeline Road. We are on Booth Calloway north of West Pipeline. You can get to the office from Booth Calloway and pull into the parking lot in front of the Professional building or the new Building. We are located in the new building to the right of the Professional Building on the right, if you are facing west. Come in the main entrance, go to the elevators to the fourth floor. Upon exiting the elevator, proceed to the right to suite C Medical Centre Drive Arlington, TX DIRECTIONS: Heading West on I-30, exit Cooper Street. Turn left at the light. Turn right on Fuller. Fuller Street becomes Medical Centre Drive. Our office is in the third group of office buildings. Heading East on I-30, exit North Fielder. Turn right at the light. Turn left on Randol Mill. Turn right on Magnolia. Turn left on Medical Centre Drive.

5 PATIENT DATE PAST MEDICAL HISTORY Please explain briefly why you are here to see the doctor: List all ALLERGIES to food or drugs: CURRENT MEDICATIONS: (including inhalers) Name of Medication Strength # times daily Length of Use Who does your insurance company require you to use for: Lab X-ray Pharmacy Phone Date of last flu vaccine Date of last Pneumovax SURGICAL HISTORY What types of surgeries have you had in the past, and when? Have you ever been hospitalized for anything other than the above surgeries? If yes, please explain. Have you ever been diagnosed with any form of cancer? If yes, please explain. Have you ever had (please circle): High Blood Pressure Heart Trouble Diabetes Kidney Trouble FAMILY HISTORY Father: Living? No Yes Age: Health problems or cause of Mother: Living? No Yes Age: death: Health problems or cause of Brother: Living? No Yes Age: death: Health problems or cause of Sister: Living? No Yes Age: death: Health problems or cause of death: List any disease that "runs in the family" (tuberculosis, diabetes, cancer, heart disease, kidney trouble, mental illness, stroke):

6 SOCIAL HISTORY Do you drink alcohol? No Yes How much on a daily basis? Do you smoke cigarettes? No Yes How much on a daily basis? If no, have you ever smoked? No Yes When did you quit? Packs/day Number of years Do you have pets? No Yes What kind? REVIEW OF SYSTEMS Please indicate the symptoms you currently have or have had: RESPIRATORY SYSTEM: Productive/Nonproductive chronic cough Blood in sputum Asthma as a child Pain in chest on deep breathing Asthma or shortness of breath Recurrent or frequent bronchitis Snoring Wheezing Sarcoid Positive TB skin test Tuberculosis (TB) Exposure to asbestos Exposure to dust/fumes Night sweats CARDIOVASCULAR SYSTEM: Palpitations Swelling of feet Sitting up in bed at night to get a good breath Leg pain Pain in chest going down into left arm Awakening at night short of breath GASTROINTESTINAL SYSTEM: Poor appetite Excessive gas Vomiting Nausea Reflux/heartburn Diarrhea Bloody stools Change in bowel habits Jaundice Hemorrhoids Constipation Use of laxatives Difficulty swallowing HEENT: Swollen lymph nodes Headaches Dizziness Failing vision Spots before eyes Watering of eyes Itching of eyes Frequent colds Nose bleeds Fever blisters Sore tongue False teeth Trouble with sinuses Hoarseness Bleeding gums Swelling of neck Pain on moving neck Goiter Glaucoma Cataracts Thyroid Hard of hearing Postnasal drip Seizures MUSCULOSKELETAL SYSTEM: Easy bruising or bleeding Joint pain or stiffness Muscle pain Gout Backaches Weakness Fractures Restless legs GENITOURINARY SYSTEM: Pain on urination Blood in urine Swelling of face or hands Surgery of prostate Trouble starting stream Frequent urination AIDS

7 TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A. Advanced Practice Provider Consent This facility has on staff advanced practice providers to assist in the delivery of pulmonary care. These advanced practice providers are not physicians. They have received advanced education and training in the provision of health care. Each can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. I have read the above and hereby consent to the services of an advanced practice provider for my health care needs. I understand that at any time I can refuse to see the advanced practice provider and request to see a physician. Name Date Signature

8 PATIENT REGISTRATION FORM Date: Patient Name Birth Date Sex SSN Last First Middle Are you currently residing in a skilled nursing facility? Yes No If yes, name of facility Home Address Street City State Zip+4 Home Phone Cell Phone Work Phone Preferred contact method for reminders (select one or more): Text (cell phone above) Voice message (circle preferred number above) (below) Do Not Contact address Patient Employer Employer Address Employer Phone I decline access to the portal Street City State Zip+4 Marital Status Religious Preference Patient Language Ethnicity Latino/Hispanic Other Decline to Answer Race American Indian or Alaskan Native Asian Asian Pacific American Black/African American Caucasian (White) Hispanic More Than One Race Native American Native Hawaiian Other Race Pacific Islander Subcontinent Asian American Unknown Decline to Answer Spouse s Name Spouse s Employer Spouse s Work Phone Address Referred By Phone Fax Address Street City State Zip+4 Primary Care Physician Phone Fax Address Street City State Zip+4 List other physicians you are currently seeing Notify in case of emergency (Do not list anyone who lives with you) Name Phone Relationship Address Street City State Zip+4 Have you signed a: Living Will: Yes No DNR (Do Not Resuscitate): Yes No (Please provide a copy) Durable Power of Attorney: Yes No Date signed: (Please provide a copy) Pharmacy Phone Are you currently using a DME (Durable Medical Equipment) Company? Yes If yes, which one? If no, who does your insurance company require you to use? Who does your insurance company require you to use for: Lab X-ray Is this a work-related illness/injury? Yes No Date of illness/injury Date last worked Cause of accident, if any I hereby authorize release of my medical records from to Texas Pulmonary & Critical Care Consultants, PA. No Signature of Patient or Responsible Party Date

9 FINANCIAL POLICY PRIMARY INSURANCE POLICY: Insurance Co. ID No. Group No. Name of Insured Insured s DOB Ins Start Date Relationship to Patient SSN Sex Claims Mailing Address Co-pay Phone No. SECONDARY INSURANCE POLICY: Insurance Co. ID No. Group No. Name of Insured Insured s DOB Ins Start Date Relationship to Patient SSN Sex Claims Mailing Address Co-pay Phone No. Responsible Party Name Phone Relationship Address Street City State Zip+4 Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you read and sign prior to any treatment. All patients must complete our Information and Insurance Form before seeing the doctor. Full payment or copayment (if applicable) is due at the time of service. We accept cash, check, Visa, MasterCard, Discover or American Express. Regarding Insurance We cannot bill your insurance company unless you give us your insurance information. If we are nonparticipating with your insurance, and they have not paid the balance within 90 days, the balance will be transferred to you. Please be aware that some, and perhaps all, of the services provided may be non-covered services and/or not considered reasonable and necessary under the Medicare Program and/or other medical insurance. These charges will be your responsibility. Our office makes every effort to obtain referral authorizations from the Primary Care offices for patients on HMOs. Should we not be able to obtain a referral, charges will be your responsibility. Out of Network Billing The physicians may not be participating physicians with your insurance plan, and if not, benefits may be reduced as such. You will be responsible for any unpaid charges and/or balances. Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company s (excluding Medicare) arbitrary determination of usual and customary rates. Missed Appointments Unless canceled at least 24 hours in advance, our policy is to charge for missed office and oximetry appointments at the rate of $25.00 and a separate charge for sleep testing at the rate of $ Please help us serve you better by keeping scheduled appointments. Signature of Patient or Responsible Party Date Research Consent I give permission for clinical and physiologic data from my medical records to be used for educational and research purposes. I understand that my identity and contact information (name, SS#, birth date, address, etc.) will never be attached to or processed with such data. Signature of Patient or Responsible Party Date

10 Appointment of Authorized Representative Identifying Information Patient s name Member s name Member s address Member s plan identification # Provider s plan identification # Service not paid / not authorized by plan Date(s) of service Appointment. I,, appoint Texas Pulmonary & Critical Care Consultants, P.A. and/or Sleep Consultants, Inc. to act as my authorized representative in requesting an appeal from in the event of denial of services/denial of payment. Directed payment. I agree that if the payment denial is overturned on appeal, the plan s payment should be paid directly to my authorized representative, and direct the plan to do so in that event. Member s signature Date

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12 Texas Pulmonary & Critical Care Consultants, P.A. Sleep Consultants, Inc. Acknowledgment of Review of Notice of Privacy Practices I have reviewed this office s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document. Signature of Patient or Personal Representative Date Name of Patient or Personal Representative Description of Personal Representative s Authority

13 Texas Pulmonary & Critical Care Consultants, PA Consent to release Protected Health Information (PHI) I understand that in order to disclose my PHI, Texas Pulmonary & Critical Care Consultants, PA, must have my consent, therefore I authorize Texas Pulmonary & Critical Care Consultants, PA to disclose my PHI as described in the provided forms to the recipients listed below: Description of the information to be disclosed (check all that apply) All Procedures Test Results Appointments Other Surgeries Billing/Account information Name(s) of the person(s) authorized to obtain the above-mentioned information. (e.g. physician other than your referring doctor, family members and other specified person/persons) Name: Relationship: Name: Relationship: Contact Information: I authorize Texas Pulmonary & Critical Care Consultants, PA to contact me at the following number with results or questions: Home Cell Work May we leave a detailed message on your answering machine or voic ? Yes No Failure to check one of these boxes may delay results By Patient: (print and sign) Date: Or Patient s Representative (print name, sign and describe authority) Date: Authorization expires one year from signature date. In signing this HIPAA Patient Acknowledgement form, you acknowledge and authorize, that you hold harmless this Healthcare Facility, its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring from this authorization. I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law; that this authorization remains effective until this Healthcare Facility is in actual receipt of a signed revocation or until the records retention period required under federal and state law has expired and the records have been destroyed; that I have the right to revoke this authorization at any time, provided I do so in writing; that I have been given the opportunity to ask questions; that I have received a copy of the signed authorization; that I may inspect a copy of my PHI to be used or disclosed under this authorization; that this Healthcare Facility has not conditioned provision of services to or treatment of me upon receipt of this signed authorization; and that I may refuse to sign this authorization. A copy of this signed, dated Authorization shall be as effective as the original. A copy of our Notice of Privacy Practices will be provided at your request.