PATIENT INFORMATION Patient Information 1 BIRTHDATE AGE SOCIAL SECURITY ADDRESS MIDDLE NO. STREET APT. NO. MALE FEMALE REFERRING DOCTOR TELEPHONE EMAIL CITY STATE ZIP PRIMARY CARE DOCTOR HOME WORK CELL OF SPOUSE OR PARENT OR GUARDIAN OCCUPATION DRIVER S LICENSE #: EMPLOYER EMPLOYER ADDRESS EMERGENCY CONTACT PRIMARY PRIMARY INSURANCE POLICY NUMBER Insurance Information 2 CARDHOLDER S CARDHOLDER DATE OF BIRTH CARDHOLDER S SOCIAL SECURITY # CARDHOLDER S RELATIONSHIP TO PATIENT REFERRAL REQUIRED * COPAY AMOUNT * REFERRAL OBTAINED *If you are unsure about your specialist co-pay amount or if you are required to have a referral from your primary care doctor to be seen by our office, call the number on the back of your insurance card to verify prior to your appointment. SECONDARY SECONDARY INSURANCE POLICY NUMBER CARDHOLDER S CARDHOLDER S SOCIAL SECURITY # CARDHOLDER S RELATIONSHIP TO PATIENT COPAY AMOUNT * REFERRAL REQUIRED * REFERRAL OBTAINED PLEASE PRESENT ALL INSURANCE CARDS & REFERRALS TO THE RECEPTIONIST Assignment 3 I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled to Surgical Specialists of Northern Virginia, LLC for services rendered by Surgical Specialists of Northern Virginia, LLC. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I hereby assume financial responsibility for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment. I understand that Surgical Specialists of Northern Virginia, LLC and/or the National Breast Center reserve the right to pursue delinquent accounts via third party collection agencies or attorneys. In the event that this account is referred to collections, I agree to be responsible for all costs of collections including attorney s fees in the amount of 25% of the outstanding balance due at the time of referral to collections. I agree to pay 1 & 1/2 percent per month interest (18% per year), on all accounts which are unpaid after (30) days. I further state that this contract is being executed in Fairfax County, and agree that venue for any action to collect unpaid bills shall be in Fairfax County, Virginia. Signature Date
PRIVACY PRACTICES ACKNOWLEDGEMENT AND CONSENT FORM I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treat ment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as the business aspects of running the practice on a daily basis. I have read and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. Patient Name: Date: Signature: Relationship to Patient: Name if other than patient:
CARE ACCESSS POLICY We have created new office standards that will enable us to offer more timely appointments to you. If you need to reschedule for any reason, please call us so we can accommodate you, and make your spot available to another patient who needs it. Because we are a cancer screening and treatment center, we have developed a cancellation policy to maximize access for urgent appointments and limit wait times for those with the greatest need. $50 Per Missed Appointment Without 24 Hour Prior Notice $100 Per Missed Procedure Without 24 Hour Prior Notice $250 Per Elective Surgery Cancellation Without 1 Week Notice I understand and agree to abide by the above policy. Patient Name (printed) Patient Signature: Date Signed Responsible Party Name (printed) Responsibily Party Signature: Date Signed Special Reminder Bringing your discs, films, reports, insurance card, and correct referral (if your insurance requires it) can help keep your care treatment plan on track. In most cases, you will need to go the imaging facility to pick up the actual films and reports; imaging facilities usually do not send them in the mail. Be sure you have everything with you the day of your visit and allow at least 2 hours plus your travel time, in case we need to run additional tests for you. We plan to work together with you as a team and we promise to give you our very best at every appointment.
CONTACT ME 1 It is imperative that we be able to reach you in a timely manner in order to enable us to provide you with the best quality care. As a consideration for our staff and patients, we ask that you provide effective contact information to our office. BIRTH DATE MALE FEMALE The best number to reach me: This is my cell home work number other Please only call me at this number between this time window: am/pm to am/pm I authorize the National Breast Center to leave messages containing the following info at the above number: appointment reminders medical information billing information Other phone numbers that messages regarding appointment reminders and call back requests can be left: this is my number this is my number this is my number I would be happy to receive appointment reminder text messages at this number 2 I would be happy to receive email correspondence at regarding my appointment reminders medical information billing information 3 I designate the following person(s) as an authorized contact for the National Breast Center to speak to about my medical situation. Name: Relationship to patient: Best phone number to reach: Name: Relationship to patient: Best phone number to reach: Name: Relationship to patient: Best phone number to reach: Signature Date
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION At times it may be necessary for us to obtain copies of reports and medical records that are related to your condition from other facilities. The following release is used to give us permission to request your records. BIRTH DATE SOCIAL SECURITY # I request and authorize to release healthcare information of the patient named above to: National Breast Center 8988 Lorton Station Blvd. 202 Lorton, VA 22079 Fax 703-763-4355 This request and authorization applies to: Healthcare information relating to the following treatment, condition, or dates: All healthcare information Other: Patient Signature: Date Signed
MEDICAL QUESTIONNAIRE PAST SURGICAL HISTORY BIRTH DATE List All Prior Surgeries and the Year They Were Done 1. Year 2. Year 3. Year 4. Year 5. Year 6. Year 7. Year 8. Year 9. Year 10. Year MALE FEMALE MEDICAL HISTORY Please mark any condition you have been diagnosed with: Arthritis Asthma Emphysema COPD Kidney Disease Thyroid Disease Diabetes Type I Type II High Blood Pressure Stroke Heart Problems Palpitations Chest Pain Other HIV / AIDS High Cholesterol Cancer REVIEW OF SYMPTOMS (Please mark all that apply) GENERAL Weight Loss / Gain Fever / Chills Bleed / Bruise Easily Blood Transfusion Anemia URINARY TRACT PROBLEMS Frequent Urination Blood in Urine Prostate Trouble STOMACH PROBLEMS Constipation Diarrhea Nausea / Vomiting Ulcers Heartburn Liver Disease LUNG PROBLEMS Cough Shortness of Breath NEUROLOGICAL PROBLEMS Seizures Head Injury Date: Type: Headaches Numbness / Weakness Location:
MEDICAL QUESTIONNAIRE BIRTH DATE CURRENT MEDICATIONS Dosage 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. ALLERGY Reaction (Circle One) Symptoms 1. Mild Moderate Severe 2. Mild Moderate Severe 3. Mild Moderate Severe 4. Mild Moderate Severe 5. Mild Moderate Severe 6. Mild Moderate Severe 7. Mild Moderate Severe 8. Mild Moderate Severe 9. Mild Moderate Severe 10. Mild Moderate Severe SOCIAL HISTORY Occupation Do You Smoke? Yes No Amount Do You Drink Alcohol? Yes No Amount Do You Use Recreational Drugs? Yes No Amount FAMILY HISTORY (Please Indicate Relationship: ) Cancer Mother Father Sibling Maternal Grandparent Paternal Grandparent High Blood Pressure Mother Father Sibling Maternal Grandparent Paternal Grandparent Diabetes Mother Father Sibling Maternal Grandparent Paternal Grandparent Stroke Mother Father Sibling Maternal Grandparent Paternal Grandparent Heart Disease Mother Father Sibling Maternal Grandparent Paternal Grandparent Thyroid Disease Mother Father Sibling Maternal Grandparent Paternal Grandparent
BREAST QUESTIONNAIRE AGE BIRTHDATE DATE Referring Physician(s): Date of Last Mammogram: Location (What facility?) Date of Last breast ultrasound: Location (What facility?) Current problem(s) / concern(s): (mark all that apply) Which breast: Left Right Both Abnormal imaging Pain Nipple discharge 2nd opinion Lump When noticed? By whom? Has it changed? No Yes How? Does if vary with your natural menstrual cycle? No Yes How? Have you had a biopsy for this? No Yes Results? Skin Changes Other Do you perform self breast exams? No Yes How often? Do you regularly consume caffiene (coffee, tea, soda, chocolate)? Daily Weekly Other Have you had other breast problems? No Yes Type of problem? Which breast: Left Right Both When? Results: Have you had breast cancer in the past? No Yes When? Was it invasive? No Yes Don t know Treatment: Chemotherapy? No Yes Radiation? No Yes Have you ever taken: Tamoxifen Arimidex Femara Other anti estrogens When? How Long? Reason? Are you currently breastfeeding? No Yes Have you breastfed in the last 6 months? No Yes Do you still have periods? Yes - Start date last menses No - Age at menopause? Natural Surgical Chemo Birth Control Induced Ovaries Removed: one both Hysterectomy - reason for Have you ever taken birth control pills: No Yes How long?: Start (month / year): Stopped (month/year): Have you ever taken fertility drugs? No Yes When? How Long? Have you ever taken hormone replacement therapy (estrogen/progesterone)? No Yes What type of hormone replacement therapy? How long?: Start (month / year): Stopped (month/year): Have you ever had genetic testing for breast or ovarian cancer? No Yes Results
FAMILY HISTORY SCREENING QUESTIONNAIRE AGE BIRTHDATE DATE Are you adopted? Yes No Please list any family history (mother, father, grandparent, sister, brother, aunt, uncle, cousin, niece, nephew) who has or has had any of the listed forms of cancer: No known family history Relationship to You Mother s side or Father s side Type of Cancer (including breast, ovarian, colon, pancreatic) Approximate Age of Diagnosis Ex. Aunt M F breast ovarian colon pancreatic 65 What is your nationality (country of origin)? Mother s side: Father s side: Ancestry and Clinical History: Western/ Northern Europe Ashkenazi Central/ Eastern Europe Latin American/ Caribbean Africa Asia Near East/ Middle East Native American Other Don t know