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1 Hello, and welcome to Arizona Pulmonary Specialists, Ltd. You are scheduled to see on at. Please plan to arrive 20 minutes prior to this time. If you are unable to keep this appointment for any reason, we require that you provide us with at least 24 hours advance notice. We require a working telephone number to confirm your appointment. If we are unable to speak with you to confirm your appointment we will assume you no longer require to be seen and your appointment will be assigned to a different patient. We reserve the right to charge for appointments missed or cancelled within 24 hours!! Our address is: 3330 N 2 nd Street, Suite 300 Phoenix, AZ Phone: Fax: Enclosed are directions to our office. Please bring the following items with you: The Patient Registration form, Medical History and Pulmonary Questionnaire completed (attached). Your most recent chest x-rays, films or disc, unless other arrangements have been made. Your insurance card(s) A list of your current medications including dosages Your copayment, if applicable (we accept all major credit cards as well as cash or check) Any pertinent medical records Any recent lab results If you have any questions about your appointment, what you need to bring, or need specific directions, please call our office at (602) , during normal business hours, which are Monday through Friday, 9:00 AM to noon and 1:00 PM to 4:30 PM. We look forward to seeing you!
2 Directions to our office: From I-17: Take the Indian School Road exit. Go east on Indian School Road approximately 2 miles. Turn right (south) on 3rd Street. Go 1/4 mile to Osborn Road and turn right (west). Go to 2 nd Street and turn left (south). Our office sets on the southwest corner of 2 nd street and Osborn. The parking garage is in the back of the building. From I-10: Take the 7 th Street exit. Go north on 7 th Street approximately one and a half miles to Osborn Road. Turn left on Osborn Road to 2 nd Street. Turn left on 2 nd Street. Our office sets on the southwest corner of 2 nd Street and Osborn. The parking garage is in the back of the building. From SR 51: Take the Indian School Road exit. Go west on Indian School Road to 7 th Street. Turn left (south) on 7 th Street to Osborn Road. Turn right (west) on Osborn Road to 2 nd Street. Turn left onto 2 nd Street, our office sets on the southwest corner of 2 nd Street and Osborn. The parking garage is in the back of the building. The parking garage is free for patients to park in. There is also a limited patient drop-off area on the east side of the building.
3 Notice of Privacy Practices ARIZONA PULMONARY SPECIALISTS, LTD. To our patients. This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Our commitment to your privacy Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information: Use and disclosure of your health information in certain special circumstances The following circumstances may require us to use or disclose your health information: 1. To public health authorities and health oversight agencies that are authorized by law to collect information. 2. Lawsuits and similar proceedings in response to a court or administrative order. 3. If required to do so by a law enforcement official. 4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat. 5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 6. To federal officials for intelligence and national security activities authorized by law. 7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. 8. For Workers Compensation and similar programs.
4 Your rights regarding your health information 1. Communications. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests. 2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. 3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to the Medical Records Department at Arizona Pulmonary Specialists, Ltd., at the office address. You may call the office for more information. 4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Arizona Pulmonary Specialists, Ltd., at the office address. You must provide us with a reason that supports your request for amendment. 5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact our front desk receptionist. 6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact the Privacy Officer at Arizona Pulmonary Specialists, Ltd. at the practice address. All complaints must be submitted in writing. You will not be penalized for filing a complaint. 7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.
5 CHECKED PATIENTS PHOTO ID ARIZONA PULMONARY SPECIALISTS, LTD. PATIENT S NAME last first m.i. DATE BIRTHPLACE _ BIRTH DATE SEX M F AGE HOME ADDRESS number street apt # city state zip code HOME # CELL# WORK # PRIMARY LANGUAGE: SOCIAL SECURITY # _MARITAL STATUS EMPLOYED BY OCCUPATION EMPLOYER S ADDRESS BUS. PHONE AT WHICH NUMBER MAY WE LEAVE A MESSAGE? HOME WORK CELL OTHER NONE NAME OF SPOUSE AGE BIRTH DATE SOC.SEC.# BUS. PHONE EMPLOYED BY OCCUPATION EMPLOYER S ADDRESS CLOSEST RELATIVE (other than spouse) IN CASE OF EMERGENCY: NAME RELATIONSHIP PHONE ADDRESS number street city state zip code WITH WHOM MAY THE DOCTOR DISCUSS YOUR MEDICAL CONDITION? name relationship name relationship REFERRED BY PRIMARY CARE PHYSICIAN Phone: BY PROVIDING THE ABOVE INFORMATION I AUTHORIZE ARIZONA PULMONARY SPECIALISTS, LTD, ITS EMPLOYEES OR ITS APPOINTED AGENTS TO CONTACT ME REGARDING MY CARE. I HAVE RECEIVED THE NOTICE OF PRIVACY PRACTICES OF ARIZONA PULMONARY SPECIALISTS, LTD. I HEREBY AUTHORIZE ARIZONA PULMONARY SPECIALISTS, LTD., OR ITS APPOINTED AGENTS, TO FURNISH INFORMATION TO INSURANCE CARRIERS OR OTHER 3 RD PARTY PAYORS CONCERNING MY ILLNESS AND TREATMENT, TO INCLUDE REVIEW ACTIVITIES RELATED TO MY PHYSICIAN S PARTICIPATION WITH MY HEALTH PLAN. I FURTHER AUTHORIZE MY INSURANCE CARRIER TO PAY DIRECTLY TO SAID PHYSICIAN GROUP ALL MEDICAL AND SURGICAL EXPENSE BENEFITS ALLOWABLE, AND OTHERWISE PAYABLE TO ME UNDER MY CURRENT INSURANCE POLICY, AS PAYMENT TOWARD THE TOTAL CHARGES FOR PROFESSIONAL SERVICES RENDERED. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO PAY, IN A CURRENT MANNER, ANY BALANCE OF SAID PROFESSIONAL SERVICE CHARGES OVER AND ABOVE THIS INSURANCE PAYMENT. A PHOTOCOPY OF THIS AUTHORIZATION SHALL BE AS EFFECTIVE AND VALID AS THE ORIGINAL. SIGNATURE DATE
6 INSURANCE INFORMATION (TO BE COMPLETED ONLY IF YOU DO NOT HAVE YOUR INSURANCE CARDS) PATIENT NAME: _ DOB: MEDICARE NUMBER PRIMARY INSURANCE COMPANY NAME OF INSURED RELATIONSHIP _ BILLING ADDRESS CITY, STATE, & ZIP CODE GROUP NAME SUBSCRIBER OR CERTIFICATE NUMBER GROUP NUMBER SECONDARY INSURANCE COMPANY NAME OF INSURED RELATIONSHIP _ BILLING ADDRESS CITY, STATE, & ZIP CODE GROUP NAME SUBSCRIBER OR CERTIFICATE NUMBER GROUP NUMBER OTHER INSURANCE NAME OF INSURED RELATIONSHIP _ BILLING ADDRESS CITY, STATE, & ZIP CODE GROUP NAME SUBSCRIBER OR CERTIFICATE NUMBER GROUP NUMBER
7 NAME: DOB AGE Date: Illnesses and Symptoms Check the if you have / have had the following: Eye Disease Ear Disease Nose / Sinus Disease Mouth / Throat Disease Seizure Disorder / Convulsions Frequent Severe Headache Paralysis Loss of Sensation Thyroid Disease Skin Disease Heartburn Ulcer Other Stomach Trouble Liver Disease / Hepatitis Bowel Disease / Colitis Change in Bowel Habits Rectal Bleeding Black, Tarry Stools Arthritis Anemia Night Sweats Sexually Transmitted Disease Weight Loss (Recent) Weight Gain (Recent) Chest Pain Palpitations / Fluttering Heart Swelling Feet, Ankles Heart Attack Kidney Disease / Stones Bladder Disease Blood in Urine Urinary Difficulty Prostate Trouble Immunizations Diabetes Psychiatric or Emotional Illness Alcohol Use IV Drug Use Frequent Aspirin, Tylenol, etc Occupation (Former occupation if retired) Pneumonia Flu Date Date Family History Current age or Health Problems age at death Father Mother Sisters / Brothers Children Women Date of Last Menstrual Period
8 Name: DOB: AGE: Date: Reason for Your Visit Today:_ Chest X-Ray Have you ever had a Chest X-Ray? Yes No If yes, when was your most recent chest x-ray taken? Date: Facility: Was it: Normal Abnormal (describe) Pulmonary Profile Check the if you have / have had the following: Cough (persistent) Frequent morning cough Mucus (Sputum) production..... Cough up blood Shortness of breath with strenuous exercise Asthma Exposure History Emphysema Have you ever smoked? Yes No Pneumonia Do you currently smoke? Yes No Pleurisy If quit, when did you quit? Lung Cancer Age when started smoking TB (tuberculosis) Total number of years smoked with moderate exercise Positive TB skin test.. Average # packs per day with normal activity Valley Fever Have you had occupational or hobby at rest Positive skin test.... exposure to: while lying down Lung Operation Asbestos Mining Other lung problems... Other toxic materials Wheeze: with colds (explain) List pets, animals, or birds at home: with exercise seasonally most of the time Medicines You Are Taking Include prescription and non-prescription drugs Medicine Allergies/Food Allergies Hospitalizations and Surgery List major illnesses and operations and approximate year Have you ever had a blood transfusion? Yes No
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NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
Alldent Dental Center Patient Registration
Patient Registration DATE Patient Name Age Address Home Phone Cell City State Zip Email Social Security # Date of Birth Sex: M F Single Married Divorced Widowed Separated Employed by Occupation Business
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD DATE PATIENT INFORMATION OUR DOCTOR CHART NO. LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME Are you
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
Welcome to Dr. Moritis Dental Office
Welcome to Dr. Moritis Dental Office Patient Information First Last M.I. Address City State Zip Home Phone Work Phone Cell Phone Email Social Security # Birth date Gender M F Marital Status Single Married
Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
OrthoVirginia Registration Information 2016
OrthoVirginia Registration Information 2016 Patient Information Patient Name Account # Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex Male Female City, State
MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form
MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form Front Office Person calls in for a new patient appointment. o Never seen at SWAN o Previously Seen at SWAN The following
Your appointment is scheduled for at.
2300 California St., Suite 300 San Francisco, CA 94115 Lee K. Schwartz, M.D. Thomas M. Swift, O.D. Margaret P. Liu, M.D. Tel: 415-921-7555 Fax: 415-921-1475 www.pacificeyespecialists.com Dear Patient:
INSURANCE INFORMATION FINANCIAL AGREEMENT PRIVACY POLICY (HIPAA) LIFETIME INSURANCE AUTHORIZATION
PATIENT INFORMATION: DATE: NAME (LAST, FIRST, MI) ADDRESS CITY, STATE, ZIP PHONE ALTERNATE PHONE BIRTHDATE SEX MARITAL STATUS SOCIAL SECURITY RACE/ETHNICITY (please circle): American Indian or Alaskan
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female
PATIENT DATA SHEET PATIENT INFORMATION Please complete this form in its entirety prior to your first visit. Also, please bring your insurance information and/or cards to our office at your first visit.
MEDICAL HISTORY AND SCREENING FORM
MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems
CONSENT FOR MEDICAL TREATMENT
CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern
Beach Family Doctors Medical Group
Beach Family Doctors Medical Group Welcome to our practice! Office Hours / After Hours 8:30am-5:00pm Monday through Friday; Closed for lunch; Closed all major holidays. For urgent medical issues after
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
NORTHEAST SPINE & SPORTS MEDICINE PATIENT INTAKE MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE#: CELL#: WORK PHONE#: S / M / D / W
NORTHEAST SPINE & SPORTS MEDICINE PATIENT NAME: PATIENT INTAKE SOCIAL SECURITY#: SEX M/F: DATE OF BIRTH: AGE: MAILING ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: HOME PHONE#: CELL#: WORK PHONE#: EMPLOYER:
How To Get A Medical Checkup
NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 APPOINTMENT TIME: (Please be at the office 30 minutes before) Welcome to NAFISA TEJPAR, M.D. PA. We appreciate
PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI
275 Collier Road NW, Suite 470 Atlanta, GA 30309 Tel: 404-351-1002 Fax: 404-350-8290 PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME
PROUGH CHIROPRACTIC 3402 Washington Rd., Suite 201 McMurray, PA 15317 PATIENT INFORMATION & CONDITION FORM
Today's Date: / / PROUGH CHIROPRACTIC PATIENT INFORMATION & CONDITION FORM Patient Name: Birth Date: / / Age: Gender: F M CURRENT ADDRESS Street City State Zip Phone ( ) Cell Phone ( ) E Mail Address If
Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone
LEWIS C. COLE DMD Family and Cosmetic Dentistry 525 ENERGY CENTER BLVD SUITE 1603 NORTHPORT, AL 35473 PHONE 205.344.6900 FAX 205.344.6910 www.lewiscoledentistry.com Patient Name: Patient Information Date:
NORTHERN EDGE PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST In order to make registration simple and quick, please use this checklist to make sure you have provided all necessary information and signatures. The process, including
Orthopedic Specialists Of SW FL New Patient Information Form
Orthopedic Specialists Of SW FL New Patient Information Form Patient Name: DOB Age M or F SS# Home Ph# Cell Ph# Work# Local Address City/State Zip Code Northern/Other Address City/State Zip Code Reason
Personal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:
Medicare Patient Information Patient Name: SS#: - - Date of Birth: / / Sex: Female Male Address: Street: City: State: Zip Code: Home Phone: ( ) - Work/Mobile Phone: ( ) - Please print your name as it Appears
Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,
Medical History Existing or Relevant Previous Conditions Allergies Yes No Dizzy Spells Yes No MRSA Yes No Anemia Yes No Emphysema/Bronchitis Yes No Multiple Sclerosis Yes No Anxiety Yes No Fibromyalgia
How To Get A Medical Checkup From A Doctor
Welcome to Schoonman Chiropractic. We look forward to providing you the best possible care. Please fill out the following information for our records: Name: Name of Parent (If Minor): Address: Phone Number:
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM Today s Date: PERSONAL INFORMATION First Name: Last Name: MI: Address: City: State/Province:
PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:
PATIENT INFORMATION: TODAY S DATE: HOW DID YOU HEAR ABOUT US?: LAST NAME: FIRST NAME: STREET CITY: STATE: ZIP: EMAIL MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED SEPARATED BIRTHDATE: AGE: SEX: MALE
Princeton and Rutgers Neurology, P.A. A Center Of Excellence
DEMOGRAPHICS Patient s Last Name: First Name: Address: City: State: Zip Code: Tel # (Cell): Tel # (Home): Tel # (Work) #: Preferred Method Of Contact: [] Cell Phone [] Home Phone [] Work Phone SS #: /
! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002
! 1220 Howell Street Ste. 110, Seattle, WA 98101 (206) 464-9002 PATIENT INFORMATION PATIENT NAME (Last, First, Middle Initial) DATE OF BIRTH AGE ADDRESS SOCIAL SECURITY NUMBER CITY, STATE, ZIP Male GENDER
UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM
UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
General Medical Questionnaire
JONATHAN S LYONS MD, THOMAS H YAU MD, LLC ROBERT P FRIEDLAENDER MD ARUSHA GUPTA MD EYE PHYSICIANS AND SURGEONS 8630 Fenton Street, Suite 514 Silver Spring MD 20910 PATIENT INFORMATION FORM (PLEASE CIRCLE)