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Microsoft word - registration & hhx forms.docx

New Patient Registration Updated Patient Registration PATIENT INFORMATION (please print) Gender: Name (First, MI, Last): ___________________________________________ Date of Birth: _____________ SS #: ____________________ Mailing Address: _______________________________________________ City: ____________________________ Zip: _____________ Address: ______________________________________________________ City: ____________________________ Zip: _____________ E-mail: ______________________________________________ Driver’s Lic: __________________________________________ Referring Doctor: ______________________________ _________ Primary Care Doctor: _____________________________ Phone: ( ) How did you hear about us? MD Friend Family LRMC News Paper _______________ On-Line: ___________ May our staff leave messages on home phone? Yes No or, with family member? Who? ___________________ Would you like to receive your test results by E-mail (Via Secure Patient Portal)? Yes No May our staff call or leave messages with your listed work number? Yes No May our staff utilize your E-mail or via secure Patient Portal for correspondence or as a means to reach you? Yes No Do you consent for our staff to obtain your current Pharmacy records/prescriptions (Electronic Prescriptions)? Current Pharmacy to send Prescriptions: ___________________________________ Phone:(_____)_________________ Address: _________________________ City: ___________________________________ State: ______ Zip: _____________ Emergency Contacts “NOT” Living with you: Employer Name: ___________________________________ 1.______________________________________________ Address: _________________________________________ 2. ______________________________________________ City: ____________________________ Zip: _____________ 3. ______________________________________________ Occupation: ______________________________________ Insurance Information (If you are Insured through someone else, please list that persons information below) Ins. Company Name: ______________________________________ ID #: __________________________________ Group/Policy #: __________________________________________ Group/Policy Name: ________________________ Subscriber’s Name: _______________________________________ Subscriber’s SSN: ___________________________ Relationship to Patient: ___________________________________ Subscriber’s Date of Birth: ____________________ Subscriber’s Employer: ___________________________________ Phone: (______)______________________________ Ins. Company Name: ______________________________________ ID #: __________________________________ Group/Policy #: __________________________________________ Group/Policy Name: ________________________ Subscriber’s Name: _______________________________________ Subscriber’s SSN: ___________________________ Relationship to Patient: ___________________________________ Subscriber’s Date of Birth: ____________________ Subscriber’s Employer: ___________________________________ Phone: (______)______________________________ Please continue on the back of this form. Patient Responsibility: You are responsible for all charges resulting from treatment provided by AGI (Advanced Gastroenterology, Inc.), we bill most insurance carriers. However, primary responsibility for the account is yours. Your co-payment is due at the time of service; any remaining balance owed by you is due when statement is received, unless other financial arrangements are made. If you have a delinquent balance, you will be expected to pay on next visit. Surgery scheduled once all accounts are current and paid in full, or if other arrangements have been made ahead of time (such as payment schedule). Minors: Patients under 18 years of age will be the responsibility of the custodial parent(s)/Guardian(s). You are responsible for notifying AGI of any cancellations or changes to scheduled appointments or procedures. Fees: Office Appointments $25 without 24 hour advanced notice. Procedure appointments $200 fee for changes or cancellations within 5 days of scheduled procedure date. On-line Patient Portal messages and other means of communication requiring doctor’s response may be charged between $25 – $100 each, (this service is not covered by your insurance). Insurance Billings: It is your responsibility (or that of the financially responsible party) to provide current, accurate insurance billing information. If your insurance information changes you must provide the new insurance information to AGI prior to receiving additional care. If your insurance coverage is not in effect at the time you receive care, or if your plan does not cover the services that you receive, you will be responsible to pay the charges. Medicare: We participate with Medicare. We will bill Medicare as your primary insurer; we will also bill your supplemental insurance provider. Medicaid: WE ARE NOT CONTRACTED WITH THIS CARRIER, You will be fully responsible for services provided to you. Check Returned: It is our office policy to charge a $35 fee for checks that are returned due to non-sufficient funds. Authorization to Release Information: In obtaining payment for services, I authorize my healthcare provider AGI to furnish information from my medical record to any company that may be responsible for payment for all or part of my provider charges, including but not limited to: my insurance companies and their representative, and my employer or union if they are involved in processing the claim. I have been provided with a copy of the Notice of Privacy Information Practices. For further information regarding disclosure of health information, please refer to the Notice of Privacy Information Practices which has been provided to you and available in our office or on our website: www.agimedical.com If I have been referred by, or am referred to another healthcare provider, I authorize AGI to release my medical information to this provider for continuing care. I also assign AGI all payments to which I am entitled for medical expenses related to the services reported herewith. I understand I am financially responsible for all charges whether covered by my insurance provider or not. I also understand that balances outstanding for more than 90 days may be subject to a processing fee. I further authorize (name of person authorized) Name: _______________________________________ Relationship to patient: Spouse Parent(s) Other: ____________________________ Including my financial account Diagnosis Treatment and/or examination rendered to me during the period of such medical or Surgical care by AGI. Please answer the following questions: Did you sustain an injury at work? Yes No Are you covered under an employer /union policy? Yes No Is your spouse/other family member employed? Yes No Do you have a secondary insurance policy? Yes No Are you covered under any other health care plan? Have you made any changes to your choice of Medicare options in the last open enrollment period? I am a new patient to this practice and am in a preexisting provision with my insurance carrier? Who is responsible for this bill? Name: Relationship to Patient: I, or my appointed agent, have read, fully understand, and agree to the above statements. I can request a copy of this policy at any time. I attest that the information I have given here is correct and true to the best of my knowledge. I understand that I am responsible for keeping the doctor updated with the current information regarding my account. If the patient is under the age of 18 years, or is otherwise unable to sign, complete the following: Patient is __________ years of age or is unable to sign because: ___________________________________________________ _______________________________________ POA / Guardian / Guarantor’s Signature Name: ____________________________________________________ DOB: _______________ Date: ________________ Reason for Visit: _______________________________________________________________________________________ Medical Problems: Please indicate if you are currently experiencing any of the following: Chronic Lung Disease Hepatitis- Type: ________ Osteoporosis Irregular Bowel Syndrome Stomach/ Duodenal Ulcer OTHER:____________ Surgeries/Procedures: Please indicate if you have Previously had a surgery or procedure below: Colonoscopy Date: _____________ Liver Biopsy Endoscopy Date: _______________ Obesity surgery: Type: ____________ Marital Status: Married Single Divorced Widowed Do you exercise? Yes No If you smoked previously, when did you Stop? __________________ Do you drink alcohol? Yes No If yes, how many drinks per day? _____ Per week? _____ Per month? ______ Do you use illicit drugs? Yes No If yes, what kind? _________________________________________________ Indicate which of the following you drink: Coffee Tea Cola Milk How many per day? ____ or _____oz’s Do you use Artificial Sweeteners? Equal Splenda Sweet N Low Truvia None Other: _______________ History of heart disease (heart attack, heart failure)? Yes No If yes, Who? ____________________________ History of Strokes? Yes No If yes, Who? _____________________________ History of high blood pressure? Yes No If yes, Who? _____________________________ History of Diabetes? Yes No If yes, Who? _____________________________ History of Cancer? Yes No If yes, Who? _________________ type: ________________ At what age? ______ History of Crohn’s Disease or Ulcerative Colitis? Yes No If yes, Who? _______________________________ Name: ____________________________________________________ Allergies: None Aspirin Morphine Penicillin Sulfa Versed Valium Other: ____________ FOOD ALLERGY: _____________________________________________________________________________________ Please indicate if you are currently taking any of the following: None Other: ____________________________________________________________________________________________ Other medications: Please include any Over-the-Counter Medication(s) . Immunizations: Current on Immunizations? Yes No Last Flu Shot Date: _________________________________ Last Pneumovax Date: ________________________________ Review of Systems: Please check what you are currently experiencing below: Weakness tiredness weight loss chills fever night sweats difficulty sleeping Double vision blurred vision yellow eyes visual disturbances Hearing difficulties ringing in ear nose bleed post nasal drip sore throat voice change Mouth sores globus sensation(feeling of lump in throat) dental problem dry mouth snoring neck pain Chest pain chest tightness Orthopnea (shortness of breath when lying down) Palpitations lower leg pain Edema chest pressure cold extremity diaphoresis (cold sweat) dyspnea on exertion reduced exercise Syncope tachycardia (rapid heart beat) intolerce Dry Cough productive cough nocturnal cough hemoptysis(coughing up blood) Wheezing pleuritic Abdominal distension abdominal mass abdominal pain anorexia belching black stools BM frequency Change in bowel habits coffee ground emesis constipation diarrhea dyspepsia dysphagia early satiety Fecal urgency flatulence gas & bloating GERD heartburn hematemesis hemorrhoids hepatitis Incontinence of stool Jaundice light colored stools loss of appetite mucus in stool nausea need for rectal bleed rectal itching rectal mass rectal pain red stools tenesmus vomiting Antacids dysuria (painful urination) burning with urination blood in urine urinary frequency urinary incontinence urinary hesitancy change in urine color urethral discharge flank pain genital lesion nocturia Oliguria Arthralgias joint swelling bone pain myalgias back pain deformity joint erythema muscle cramps Ecchymosis (bruise) excessive sweating hair loss photosensitivity pigmentation change pruritus Headache sleep disturbances numbness alteration of consciousness confusion impaired balance Impaired speech memory loss seizure syncope Depression anxiety panic attacks suicidal ideation suicidal planning Alopecia cold intolerance flushing heat intolerance polydipsia (thirst) polyphagia polyuria easy bruising bleeding gums easy bleeding petechiae prolonged infection recurrent infections Hives oropharyngeal swelling throat itching throat pain wheezing

Source: http://www.agimedical.com/wp-content/uploads/2013/06/Registration-HHX-forms.pdf

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