1 ANNA BURKE, M.D., R.D. INTERNAL MEDICINE BRITTNEY FORT, R.N., M.S.N., FNP-C VANESSA AVRUTIS, FNP-C ADULT NURSE PRACTITIONER 1614 Scripture St., Ste. 9 Denton, TX Phone: (940) Fax: (940) Dear New Patient: Welcome to our practice. We are very pleased that you have selected us for your medical care. Enclosed are forms for you to complete in advance of your appointment to assist our staff in making sure we have all the information necessary to provide you with quality care and treatment. Please fill out the forms completely. If you have any questions or problems filling out the forms, do not hesitate to call so that we may assist you. When you have completed your forms, please return them to our office prior to your appointment. This will allow our medical staff to review your medical history prior to your appointment and will allow our staff to have your chart prepared in advance in order to help prevent delays in seeing the doctor. You will be contacted prior to your appointment to confirm your visit. If you are not able to keep your appointment, please call us (940) to cancel or reschedule your appointment. Our office hours are by appointment: Monday-Friday 8:00 A.M. 12:00 P. M., 1:00 P. M. - 5:00 P.M. For urgent needs after hours, please call and you will be directed to call physician on call. Help us to help you more efficiently: If you are ill, call as early in the day as possible so that we can accommodate you promptly. Let us know if you move, change your insurance, or telephone number. Call to cancel if you are unable to make an appointment. Chronic missed appoints could result in termination of care. If a problem arises, tell us. We will do the best we can to help you. For prescription refills at a local pharmacy, please call the pharmacy and they will fax a refill request. If you receive your prescriptions by mail order, please call the office and we will submit them electronically. Once again, welcome to our practice. We look forward to providing you with quality care. Cordially, Anna Burke, M.D., R.D. Brittney Fort, R.N., M.S.N., FNP-C Vanessa Avrutis, FNP-C
2 Anna Burke, M.D., R.D. Brittney Fort, R.N., M.S.N., FNP-C Vanessa Avrutis, FNP-C 1614 Scripture, Ste. 9 Denton, TX (940) PERSONAL INFORMATION Last Name First Name MI DOB / / Sex: M F Address Home Phone Cell Phone Address City ST Zip Emergency Contact Phone Number Relationship Marital Status: S M D W Employer Pharmacy Name Phone Number GUARANTOR INFORMATION (Person responsible for bill. Use full legal name.) Last Name First Name MI SS# DOB / / Phone Number Address City ST Zip Relationship to Patient INSURANCE INFORMATION Plan Name Insured s Name (*Name of card holder*) Insured s SS# Insured s Date of Birth Policy/ID # Group # Effective Date
3 Cancer (Specify) Diabetes COPD Coronary Artery Disease Heart Disease High Cholesterol High Blood Pressure Pneumonia Stroke Thyroid Hyper/Hypo NEW PATIENT HEALTH INFORMATION PERSONAL INFORMATION Date / / Date of Last Physical Exam / / Last Name First Name MI Preferred Name DOB / / Age DRUG ALLERGIES No Known Drug Allergies (NKDA) Name of Medication or Food Allergy Reaction CURRENT PRESCRIPTION MEDICATIONS: None Name of Drug Dose (mg/mcg) # tablets/day # times per day MEDICAL HISTORY Have you or immediate family members ever had any of the following: Relationship Status To You A- Alive D- Deceased Date of Onset (If known) Self Mother Father Brother Sister Adopted not able to provide medical history HOSPITALIZATIONS/SURGERIES Illness Description Year Name of Hospital Surgery Other
4 PERSONAL HABITS Tobacco Use Status: Type: Frequency: Never smoked Have smoked Quit smoking Date quit: Cigarettes Pipe Cigars Snuff Chew Packs/# of cigars/day (circle) Number of years (circle) Alcohol Use Recreational Drug Use Yes No Yes No Beer Wine Other What? Amt. of alcohol/week Times used/week For Women Only Menstrual Period Yes No Last period: Age of onset: If no, please specify why. Hysterectomy Post-menopausal ADDITIONAL PERSONAL INFORMATION Procedure (Please indicate date of most recent procedure.) Bone Density Colonoscopy Mammogram Pap Smear PSA or Prostate Exam Eye Exam Dentist Year Immunizations (Please indicate date of most recent injection.) Flu Hepatitis A Hepatitis B Pneumonia TDaP (Tetanus) Zostavax (Shingles) Year SPECIALISTS YOU HAVE SEEN Name Specialty Phone Number Reason for Visit Date of Last Visit Do you have an Advance Directive or Living Will? Yes No Do you have a Medical Power of Attorney? Yes No
5 MEDICAL RELEASE OF INFORMATION Patient Name: Date of Birth: SS#: XXX-XX Previous Name, if applicable Home Phone: Cell Phone: I request and authorize: (Name of Physician and Clinic/Practice you want to release your records) Phone Number: (required) Fax: To release the medical record of the above named patient to: Anna Burke, MD 1614 Scripture, Ste. 9 Denton, TX (Phone) (Fax) Reason for release (required field): Health Care information relating to the following treatment condition or date of treatment: This information may contain x-ray reports, laboratory reports, EKG reports, other diagnostic reports, consults, etc. This request and authorization applies to: (initial appropriate line below) All Health Care information including information relating to HIV/AIDS testing, sexually transmitted diseases, psychiatric disorders/mental health or drug and/or alcohol use. (circle all that apply) All Health Care information excluding information relating to HIV/AIDS testing, sexually transmitted diseases, psychiatric disorders/mental health or drug and/or alcohol use. (circle all that apply) Information used or disclosed pursuant to this authorization may be subject to re-disclose by the recipient and no longer protected. Treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as for participation in research programs, or authorization of the release of testing results for pre-employment purposes. I understand I have the right to revoke this authorization by providing a written request to do so to the above named physicians or organization. I understand that the revocation will not apply to all information that has already been released in good faith. I understand that the condition for release is not based on payment for treatment and care, enrollment or eligibility on whether I sign the authorization. Signature of Patient or Authorized Representative Date Relationship or status if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.) I understand that authorizing the disclosure of this health information is voluntary.
6 APPOINTMENT/CANCELLATION/NO SHOW PROCEDURES SCHEDULED APPOINTMENTS We understand that delays can happen; however, we must keep the other patients and providers on time. If a patient is 10 minutes past the scheduled time for a regular office visit or a physical exam, we will have to reschedule the appointment. CANCELLATION or NO SHOW We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. If you cannot make your scheduled appointment time, please call to reschedule. We request that you give our office 24 hour notice in the event you need to cancel or reschedule your appointment. If you do not contact our office, we consider this to be a No Show appointment. Excessive cancelled appointments may result in you being dismissed from the practice. If we do not receive a call 24 hours in advance, you will be charged a no show fee of $25.00 for a regular office visit and $50.00 for a physical exam. More than three no shows may result in you being dismissed from the practice. As a courtesy, we provide an appointment card/ a reminder call and/or for appointments. If you do not receive your reminder call or message, the cancellation policy will still remain in effect. You are responsible for remembering your appointment. If you have any questions regarding these procedures, please let our staff know and we will be glad to provide clarification. I have read and understand the Appointment/Cancellation/No Show Procedures and agree to be bound by the terms. Printed Name of Patient/Guardian Date Signature of Patient/Guardian
7 FINANCIAL RESPONSIBILITY AGREEMENT Patient Name: Date of Birth: I understand and agree that I will be financially responsible for any and all charges for services not paid by my insurance for my visits. This includes any medical service or visit, preventative exam or physical, lab testing, x-ray, EKG and any other screening service or diagnostic testing ordered by the physician of the physician s staff. I understand and agree it is my responsibility and not the responsibility of the physician or office to know if my insurance will pay for my medical visit, preventative exam or physical, lab testing, x-ray, EKG or any other screening service or diagnostic testing ordered by the physician or the physician s staff. I understand and agree it is my responsibility to know if my insurance has any deductible, co-payment, co-insurance, out-of-network amount, usual and customary limit or any other type of benefit limitation for the services I receive, and I agree to make full payment. I understand and agree it is my responsibility to know if the physician or provider I am seeing is a contracted in-network provider recognized by my insurance company or plan. If the physician or provider I am seeing is not recognized by my insurance company or plan, it may result in claims being denied or higher out-of-pocket expense to me. I understand this and agree to be financially responsible and make full payment. I understand and agree it is my responsibility to know if my PCP (primary care physician) choice has been processed by my insurance company or plan. If I have requested a PCP change that is not processed by my insurance company, it may result in claims being denied. I understand this and agree to be financially responsible and make full payment. I understand that the physician may charge $25.00 for regular/sick appointments and $50.00 for physicals if I do not show up for my appointment or I cancel without twenty-four hour notice. Patient Signature: Date: (Please sign here Patient or Responsibility Party) Responsible Party Name: (Please print name of Responsible Party, if different from Patient)
8 PATIENT DISCLOSURES & CONSENTS Patient Name: Date of Birth: ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize direct payment of my insurance benefits to Texas Health Physicians Group or the physician individually for services rendered to my dependents, or me, by the physician or those under his/her supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance due that Texas Health Physicians Group is unable to collect from my insurance carrier for whatever reason. MEDICAL/MEDICAID/CHAMPUS INSURANCE BENEFITS: I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my dependent s records that these programs may request. I hereby direct payment of my or my dependent s medical or incidental nonpublic personal information that may be necessary for medical evaluation, treatment, consultation or the processing of insurance benefits. AUTHORIZATION TO RELEASE NON-PUBLIC PERSONAL INFORMATION: I certify that I have read and been offered a copy of the Texas Health Physicians Group HIPAA Notice of Privacy Practices. I hereby authorize the Texas Health Physicians Group or the physician individually to release any of my or my dependent s medical or incidental nonpublic personal information that may be necessary for medical evaluation, treatment, consultation or the processing of insurance benefits. AUTHORIZATION TO MAIL, CALL OR I certify that I understand the privacy risks of the mail, phone calls and . I hereby authorize a Texas Health Physicians Group representative or my physician to mail, call or me with communications regarding my healthcare, including but not limited to such things as appointment reminders, referral arrangements and diagnostic test results. I understand that I have the right to rescind this authorization at any time by notifying Texas Health Physicians Group to that effect in writing. LAB/X-RAY/DIAGNOSTIC SERVICES: I understand that I may receive a separate bill if my medical care includes lab, x-ray or other diagnostic services. I further understand that I am financially responsible for any co-pay or balance due for these services if they are not reimbursed by my insurance for whatever reason. CONSENT TO TREATMENT: I hereby consent to evaluation, testing and treatment as directed by my Texas Health Physicians Group physician or those under his/her supervision. Patient Signature: Date: Guarantor Signature: Date: (If different from patient) Guarantor Name: (Please Print):
9 PATIENT AGREEMENT FOR CONTROLLED SUBSTANCE The treatment of pain is a necessary and important part of caring for our patients. We are committed to making sure we address your pain needs while providing you with alternatives designed to minimize the addictive potential of the treatments we use. In this regard, we have a Pain Management program in cooperation with Pain Management Consultants to insure you know about and have access to the best, safest treatments available. If your pain requires ongoing prescriptions for controlled substances with significant addiction potential we will be asking you to see a specialist. Controlled substances are often addictive and must be taken exactly as prescribed. To clarify our expectations in giving you this medication and to emphasize the risk of taking these substances, we are asking you to read and sign this agreement. I,, understand that if I am prescribed a controlled substance I must adhere to the following restrictions. Failure to conform to any of the below listed restrictions may result in being dismissed as a patient and being reported to the police. 1. I will not use alcohol/illegal drugs while being prescribed medication(s). 2. I understand refills may not be written for an emergency, because one is leaving town, an unforeseen event or my controlled substance was lost or stolen. 3. I will not take any other prescribed medication without first notifying my doctor. 4. I will notify my doctor immediately of any other physician(s) currently prescribing me a controlled substance(s) or that have been prescribed to me in the past thirty days (including Emergency Rooms and Immediate Care Centers). Legally, failure to do so is a Crime (Obtaining or Attempting to Obtain Drugs by Fraud and/or Deceit) and may be reported to the police. 5. I will submit to random urine and/or serum drug screens as ordered. 6. I will purchase all of my medication(s) at pharmacy and authorize my doctor to communicate with the pharmacist. 7. I authorize my doctor to communicate with all physicians that I have seen. 8. I understand that it is illegal to share this medication. 9. I agree to keep my medication locked in order to prevent loss or theft. 10. I understand that I will be taken off this medication if there is evidence of addiction and/or abuse. 11. I understand that this medication may cause drowsiness and slower reflexes, interfering with the ability to drive and operate machinery and short-term memory impairment. 12. I agree to keep all scheduled appointments with my physician/therapist. My medication may be weaned and discontinued if I fail to attend my scheduled appointments. 13. I also understand that part of my treatment may involve reduction and discontinuation of any addictive medications. 14. I authorize this office to release a copy (or original) of this controlled substance agreement to the police, at their request, if I violate any of the listed terms. 15. Yes or No Have you received any prescription medication from any other physician in the past thirty days? If yes, please list physician and medication on the back of this sheet. 16. I understand that I may be called at any time to the office for a count of all my remaining medications. I agree to arrive on the day notified and will be responsible for any cost that may incur. 17. I waive my right of privacy and authorize my doctor to contact any healthcare provider, legal authority, friend and/or relative in order to obtain or provide information about my care (including abuse of controlled substances). 18. I fully understand that failing to meet the above conditions may result in: a. A re-evaluation of my treatment plan, b. Discontinuation of controlled substance medication therapy, and or c. Ending the provider-patient relationship.
10 I,, have read and/or the above information has been read to me, and I have been instructed on the above information. I have been given the opportunity to ask questions and all my questions regarding my duties and responsibilities as part of the treatment team in this agreement have been answered to my satisfaction. I fully understand my duties and obligations and the consequences of my failure to follow this agreement. I hereby give my voluntary consent to participate in the controlled substance medication management and acknowledge receipt of the agreement portion of this document. I have been given a signed copy of this document. Patient Printed Name: Patient Signature: Date: Physician s Signature: Date: Witness Signature: Date:
11 DISCLOSURE REGARDING ANCILLARY SERVICES/RESEARCH PROGRAMS ANCILLARY SERVICES Your physician may refer you to one or more Ancillary Services in connection with your medical care. Am Ancillary Service is a service relating to your medical care or treatment. The following types of services are Ancillary Services: Audiology Bone Density Imaging Computer Tomography (CT) Durable Medical Equipment (DME) Echo Cardiograph Infusion Therapy Laboratory Magnetic Resonance Imaging (MRI) Mammography Nuclear Imaging Positron Emission Tomography (PET) Sleep Therapy Ultrasound X-Ray Your physician may have an economic interest in or a business relationship with the company or person who provides the Ancillary Services. You are not obligated to use the provider that your physician refers you to. You are free to use any provider you choose. If you receive a referral for an MRI, CT or PET service, the following are other facilities that provide such services in the area: Clear Sky MRI (MRI, CT) 3118 Los Colinas Denton, TX (940) Corinth Pet Imaging, LP (PET) 4851 South I 35 East, Ste. 101 Corinth, TX (940) Lake Vista Cancer Center (PET) 2790 Lake Vista Dr. Lewisville, TX (940) PET/CT Imaging of North Texas (PET/CT) 2900 North I 35, #119 Denton, TX (940) Preferred Imaging of Corinth (MRI) Oak Ridge Professional Plaza 4851 Interstate Hwy 35 East, Ste. C-105 (940) Preferred Imaging of Denton (CT) 1614 Scripture St. Denton, TX (940) Texas Oncology Denton-North (PET) 2900 North I 35, Ste. 100 Denton, TX (940) Touchstone Imaging Denton (CT, MRI) 1435 Loop 288, Ste. 101 Denton, TX (940) Touchstone Imaging Flower Mound (CT, MRI)/Imaging Specialists Group, LLC (PET) 3101 Churchill Dr. Ste. 100 Flower Mound, TX (972) / (972) Touchstone Imaging Lewisville (CT,MRI) 190 Civic Circle, Ste. 125 Lewisville, TX (972)
12 RESEARCH PROGRAMS Your physician may ask if you would like to participate in a clinical trial or other research program. These programs may be sponsored by a drug company or may be part of a governmental research program. Your physician may be compensated for services rendered in connection with these programs. You are not obligated to participate in any research program and your permission will be obtained prior to your participating in a program your physician believes may be appropriate for you. Please feel free to ask your physician if you have any questions about a particular Ancillary Service or Research Program. Patient (or Guarantor) Signature: Date: Printed Name:
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