REVIEW OF MEDICAL HISTORY

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1 Patient s Name: Today s Date: Family Physician or Pediatrician: Physician s Phone Number: Physician s Address: Please Tell Us How You Found Our Practice Check ( ) those that apply: Physician Referral Internet Family Member or Friend Google Search Advertisement Yahoo Search Newspaper Yellowpages.com Marketeer Hearing Aid Dealer Yellowpages Other (Please Explain): REVIEW OF MEDICAL HISTORY Check ( ) either YES or NO for each Item YES NO YES NO YES NO GENERAL SKIN KIDNEY Fever Rash Blood in Urine Chills Changing Moles Pain while Urinating Night Sweats Pigmentation Difficulty Urinating Weight Loss HEART & LUNGS Frequent Urination General Weakness Irregular Heartbeat NEUROMUSCULAR Bruise Easily Shortness of Breath Leg Cramps Memory Loss Wheezing Leg or Arm Weakness Swollen Glands Frequent Cough Dizziness EYES Coughing Blood Balance Problems Blurry Vision Chest Pains Fainting Spells Double Vision Swollen Ankles Headaches Halos BONES Speech Problems Light Flashes Joint Pain ENDOCRINE EARS Joint Swelling Constant Thirst Hearing Loss NECK Always Feel Warm Ear Pain Stiffness Always Feel Cold Ear Drainage Swelling Often Feel Depressed Buzzing / Ringing Lumps / Bumps HABITS NOSE & THROAT GASTROINTESTINAL Do you Smoke? Sinus Problems Poor Appetite Do you Drink Coffee? Nosebleeds Indigestion / Heartburn Alcohol? Swallowing Problems Nausea / Vomiting Soda / Pop? Persistent Hoarseness Vomiting Blood Do you Fall Asleep Easily? Cough Abdominal Pain or Cramps Do you Awaken Easily? Dental Pain Diarrhea Mouth Sores Constipation Loss of Taste / Smell Blood in Stool Reasons for Hospitalizations ( none) MEDICATIONS ( if taking) NONE Hormones Antacids Iron Supplements Antibiotics Laxatives Aspirin Pheonobarbitol Anti-Inflammatory Shots Barbituates Sleeping Pills Birth Control Pills Steroids Blood Pressure Pills Thyroid Medicin Blood Thinning Pills Tranquilizers Cough Medicine Vitamins Digitalis Water Pills Dilantin Weight Loss Pills Insulin or Diabetic Pills Others (Please List): Medications you are ALLERGIC to ( none) Previous Surgeries ( none) Physician s Signature:

2 PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION PATIENTS OVER 18 YEARS OF AGE You are the only one that can receive your medical records such as your test results or office notes. Legally, we can t even give a spouse the other spouse s test results or discuss medical treatment without written permission from you. This is in accordance with the HIPAA privacy act. This form will allow those people designated by you to have access to information about your medical care. Date: I,, give permission to the physicians and staff of ENT Specialists, P.C. to discuss my medical records with: Relationship: This permission includes discussing results of examinations, x-ray s, laboratory findings, future testing to be scheduled, and information pertaining to insurance billing. I also give permission to allow the above named individual(s) to sign and receive copies of any and all medical records. Signed: Witness: PATIENTS UNDER 18 YEARS OF AGE If the parent or guardian is not present during the office visit, then children under 18 years of age cannot be seen without their parent or guardian s express written consent. This form provides authorization for consent to medical care for minor children. I/We: are the parent(s) or legal guardian(s) and legal custodian(s) (name of parent or legal guardian) of the following child: Date of Birth: (Child s name) I/We hereby authorize: with whom (name of person to be present with child on date of exam) I/we am/are temporarily entrusting the care and custody of my/our minor child, to consent to any testing, examination, anesthetic, medical, surgical, or dental treatment, surgery, or hospital care to be rendered to the minor under the general or specific supervision and on the advice of any physician at ENT Specialists, P.C. This authorization shall be effective for twelve (12) months unless stated otherwise from the date signed: Signatures: Date: (Parent / Guardian) Date: (Parent / Guardian / Witness)

3 HIPAA PRIVACY ACT With my consent, ENT Specialists, P.C. may use and disclose Protected Health Information (PHI) about me to carry treatment, payment and healthcare operations (TPO). Please refer to ENT Specialists, P.C. Notice of Privacy Practices for a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. ENT Specialists, P.C. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to ENT Specialists, P.C. Privacy Officer at Meadowbrook. With my consent, ENT Specialists, P.C. may call my home or other designated location and leave a message on voic or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any call pertaining to my clinical care, including laboratory results among others. With my consent, ENT Specialists, P.C. may mail to my home or other designated 1ocation any items that assists the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. I have the right to request that ENT Specialists, P.C. restricts 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 it does, it is bound by this agreement. By signing this form, I am consenting to ENT Specialists, P.C. 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, ENT Specialists, P.C. may decline to provide treatment to me. Signature of Patient or Legal Guardian Date Patient s Name Printed Name of Patient or Legal Guardian

4 E-PRESCRIPTIONS For your convenience and safety, we are introducing a computerized, prescription program that will improve both the accuracy and convenience of prescribing medications. This program will allow for the electronic transmission of most of your prescriptions directly to your pharmacy of choice and will eliminate your waiting time. In most cases, it will also accommodate the transmissions of your prescription to mail order pharmacies. To implement this new program, we need to collect some information from you on your pharmacies of choice. We will define one pharmacy as your main pharmacy; however, you may also provide the information for additional pharmacies to be used as an alternative. In addition, if you have a mail order benefit program, please provide that information by selecting the appropriate box below. We understand that you may not have the complete pharmacy information with you today. Please provide any information possible regarding the location (street, city, phone, fax) as any information provided will be helpful. PATIENT NAME: Date of Birth: MAIN PHARMACY: Name (i.e. CVS, Rite-Aid, etc): Street Name & City: Phone: Fax: ADDITIONAL PHARMACIES YOU WOULD LIKE KEPT ON FILE: Name (i.e. CVS, Rite-Aid, etc): Street Name & City: Phone: Fax: Name (i.e. CVS, Rite-Aid, etc): Street Name & City: Phone: Fax: MAIL ORDER: Medco (90 day mail order supply) CVS CareMark / Pharmacare Express Scripts, Inc. MedImpact

5 CANCELLATION POLICY If you are unable to keep an appointment, please call the office and give proper notification that you will be unable to do so. If you are unable to keep your appointment, please call the office within 24 hours to cancel. If you do not give us appropriate notification, you will be charged a $25 no-show fee. This must be paid in full before for your next visit. This is in an effort to allow other patients the opportunity to schedule an office visit with our physicians. We understand urgent situations may arise preventing you from keeping your appointment, we only ask for the courtesy of a phone call as soon as possible. Thank you, ENT Specialists, P.C. Patient/Responsible Party: REQUEST We would like to request your address. This will be used only for future communications directly from ENT Specialists. Your information will be kept strictly confidential and will not be given to any third party.

6 Dear Patient: INSURANCE AUTHORIZATIONS Due to the many changes in insurance policies, it is no longer an easy task to interpret each individual policy. Although we try to stay aware of these changes, it is not always possible. It is your responsibility to know your individual coverage. Failing to comply with this suggestion could result in you, the patient, being responsible for all costs incurred. Please remember your insurance policy is between you and your company and not with the insurance company and your doctor. Sincerely, ENT Specialists, P.C. SIGNED DATE PATIENTS OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical information necessary to process this claim and request payment of GOVERNMENT benefits either to myself or to the party who accepts assignment below: SIGNED I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED OR SUPPLIER FOR SERVICES DESCRIBED BELOW. SIGNED MEDICARE Name of Beneficiary HI Claim Number I request that payment of authorized Medicare benefits be made either to me or on my behalf to for any services furnished to me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I hereby authorize Medicare to furnish to the above named doctor any information regarding my Medicare claims under Title XVIII of the Social Security Act: COMMERCIAL INSURANCE I herby authorize release of any information necessary to file a claim with my insurance company and ASSIGN BENEFITS OTHERWISE PAYABLE TO ME TO THE DOCTOR OR GROUP INDICATED ON THE CLAIM. I understand I am financially responsible for any balance not covered by my insurance carrier. A copy of this signature is as valid as the original. SIGNED DATE

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