HSE Medical Associates Family Practice

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1 HSE Medical Associates Family Practice PLEASE CHECK WHICH PROVIDER YOU ARE HERE TO SEE M.D. P.A. David W. Hoefer, M.D. Paul E. Shepard, M.D. Alfredo T. Ermac, M.D. Sergio G. Perossa, Darcy Bevil, P.A. Lindsey Havel, P.A. Elizabeth Grizzaffi, P.A. Jessica Alayon, How did you hear about us? All questions must be answered completely. If you need assistance, please see the receptionist. PLEASE PRINT CLEARLY PATIENT INFORMATION: Last Name: First Name: Middle Initial: Address: Apt #: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Sex: Male Female Marital Status: M S D W NA Student Status: FT PT ****Please provide us with your insurance card(s) at the time of your visit**** Relationship of Patient to the Policy Holder Self Spouse Child Other please specify POLICY HOLDER INFORMATION: Primary Insurance: Last Name: First Name: Middle Initial: Address: Apt #: City: State: Zip Code:

2 Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: HSE Medical Associates Family Practice GUARDIAN INFORMATION Person responsible for the bill: Please fill out only if the person responsible for the patient bill is different from the policy holder s information or the patient s information. Last Name: First Name: Middle Initial: Address: Apt #: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: ASSIGNMENT OF INSURANCE AND AUTHORIZATION TO RELEASE INFORMATION I hereby authorize my current insurance company to pay directly to HSE Medical Associates benefits due me, if any, by reason of sercives described in the statement rendered and are provided for the above policy contact with the above mentioned insurance company. I will be responsible for all such charges incurred in excess of whatever sum may be paid by my insurance company. Signature: Date: MEDICARE CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION, PAYMENT REQUEST I request that payment of authorized Medicare benefits be made, whether to me or on my behalf to HSE Medical Associates, for any services provided to me by the physicians. 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 payable for related services. Signature: Date:

3 HSE Medical Associates Family Practice PATIENT PRIVACY RIGHTS UNDER THE Health Insurance Portability and Accountability Act of 1996 (HIPPA), all patients have certain rights to privacy regarding health information. This protected information can and will be used to: Conduct, plan and direct treatment and follow up among the multiple healthcare providers who may be involved directly and indirectly. Obtain payment from third party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. Patients may request, in writing, to restrict how private information is used or disclosed to carry out treatment, payment or healthcare operations. Though not required to agree to requested restrictions, we are bound to abide by agreed upon restrictions. Patients may revoke consent at any time, except to the extent that action has been taken relying on prior consent. The following page is a detailed consent form to allow/disallow any person whom you may want/not want to obtain private health information. By signing below you acknowledge that you understand that HSE Medical Associates is allowed to release/not release health information specific to your request. Patient Name (please print): Signature: Today s date:

4 HSE Medical Associates Family Practice CONSENT FOR DISCLOSURE TO FAMILY MEMBERS AND/OR PERSONAL REPRESENTATIVE CONDITIONS FOR DISCLOSURE: It is often difficult to talk to patients in person. Therefore, we must have your permission as to how we may communicate with you. Please check if you AGREE to the following conditions: HSE Medical Associates may disclose my medical information to me and to the following individual(s) in my presence and when I am not physically present, including disclosures by telephone, voice mail, fax, or mail. I have agreed to let certain individuals participate in discussions and decisions related to my medical care. Therefore, I hereby give my permission for HSE Medical Associates to disclose my personal medical information to the following individuals: Name: Relationship: Name: Relationship: Name: Relationship: If you DO NOT AGREE, please check below: I do not wish for HSE Medical Associates to disclose any of my medical information to anyone other than myself.

5 I understand that this consent may be revoked by me at any time, in writing, to HSE Medical Associates. Patient Name (please print): Patient Signature: Today s Date: We at HSE Medical Associates, are dedicated to providing the best possible medical care and service to you and your family. Your understanding of our financial responsibility policy is an essential element of your care and service. With all the new healthcare changes, we have updated our policies. This will prevent any misunderstandings and allow us to serve you better. FINANCIAL and BILLING POLICIES (Please read and initial EACH item below): 1) You are ultimately responsible for knowing what your plan does and does not cover, and the administrative rules. (i.e.: in-network/out of network: out of pocket balance, copayment, coinsurance, deductible, Health-Savings Account balances; labs/radiology/ekg; prior authorizations and referrals) 2) Each patient is encouraged to verify if specific labs/other procedures are covered or not covered (i.e.: preventive benefits & screenings such as EKG/XRays/MRI/CT and immunizations, as well as mental health office visits). Also, the percentage that each procedure or lab is covered at, such as 100%, 80%, 70% etc. 3) As a courtesy, we will verify your eligibility and benefits. However, we cannot guarantee that the information received is accurate due to insurance policy changes and real-time/up-to-date system information. We will bill your insurance company with whom we have a contract agreement. 4) Once your benefits have been determined, payments of any copays, coinsurance, deductible and fees are required at the time services are rendered. 5) Once your insurance company has processed a claim, any balance as determined by your insurance plan to be patients responsibility and/or non-covered service, will be your responsibility. 6) If you disagree with the patient responsibility amounts due to our office per your insurance s Explanation of Benefits (EOB), please immediately call your insurance company and our office for further explanation. 7) Failure to provide current insurance information to our office and/or reply back to insurance s request for additional information may result in the entire bill being your responsibility. 8) Self Pay patients: Full payment for your visit is expected on the day of the visit. 9) Any outstanding balance owed to our office is also due, unless payment arrangements have been made in advance with our office. 10) The independent labs (Quest Diagnostics, LabCorp, and North Cypress Medical Center) will also bill independently. If you receive a bill from the lab, you will need to contact the lab for further detail and payment arrangement. 11) There will be a fee for ALL forms to be filled out and/or typed letters requiring a signature from our physicians, nurse practitioners, physician assistants or any medical staff. There is also a charge for re-writing lost prescriptions. 12) Our office DOES NOT bill third parties (i.e.: automobile insurance). Your visit will be self-pay and a receipt will be given to you to file with your auto insurance. Our office DOES NOT accept workman s compensation cases. 13) Please notify us in advance if you cannot keep your appointment. We reserve the right to ask you to seek care from another physician if you miss three appointments without notification. If you are more than 30 minutes late for your appointment, you may be asked to reschedule.

6 14) There will be a $25 charge for ALL RETURNED CHECKS. GENERAL MEDICATION REFILL POLICIES: For medication refills, please call the pharmacy and speak to a technician/person. Allow at least one week left on current medication when calling the pharmacy for a refill. Allow at least 48 hours after we receive the refill request from the pharmacy to process the request. Refills will not be processed as an emergency. Please plan ahead. Patient is responsible for keeping track of the amount of medication remaining, and for taking the medication as prescribed. No refills will be made during weekends or holidays. ****Some medications require closer monitoring than others. A general outline is as follows**** Mental health medications require an appointment every 3 6 months based on individual assessment. Narcotics require an appointment for every refill. THERE ARE NO EXCEPTIONS. Triplicate prescriptions require an appointment every 3 6 months (or sooner if changes are needed). All other maintenance medications require a 3 6 month follow up appointment for consideration on therapeutic regimen and necessary blood work. It is per the discretion of the physician if an appointment will be required before a refill is granted. Many factors and circumstances are considered before a final decision is made. Thank you. Patient Name (please print) Last First Signature: Date of Birth: Date: If patient is a minor, please PRINT parent/guardian name: Things My Doctor/Provider Should Know H S E P Lindsey Darcy Elizabeth Jessica - Please circle your providers name or initial NAME: DOB: / / Personal Medical History: Please indicate whether you have had any of the following medical problems (with approximate date of illness/diagnosis): Congenital Heart Disease Coagulation/bleeding Disorder Problems: Other (Specify type) Cancer Heart Attack (Specify type) Diabetes Depression/suicide attempt High Cholesterol Alcohlism Stroke Blood Transfusion Thyroid Disease (Specify date) Date of last Tetanus Vaccine: (Specify type) Abnormal Pap Smear Past Surgical History: Please list dates of all operations with dates. Social History: Marital Status - Married Divorced Single Widowed Occupation: (circle one) Separated Co-Habitating Engaged Tobacco: Cigarettes Cigars Dip/Snuff Pipe Spouse/Partner's Name: How much?

7 Number of children: Alcohol: Yes No # drinks/week: Who lives at home with you? Drugs: Yes No Family History: Please indicate with check ( ) family members who have had any of the following conditions: High BP High Cholesterol Heart Attack Stroke Diabetes Thyroid Disease Cancer Type? Father Mother Brother Sister Child Grandparent Other How did you hear about us? Referred by friend/patient Ad ER Other Please see other side to list your medications and provide the name of other specialists Updates --- HSE Medical Associates NAME: DOB: / / Please list all of your current medications/doses (including over-the-counter & supplements): Any reactions/allergies to medications? Since your last visit - have you seen any new doctors/specialists? Yes No Please list all your current doctors/specialists:

8 Any new medical conditions/diagnoses? Yes No (over) Date MEDICAL PERMISSION TO TREAT MINOR CHILD To whom it may concern: Regarding (Give full Name of Child and Date of Birth) As the parents of the above-named child, (Name of Responsible Adult) has my permission to seek medical treatment for this child. From to or Date Date Indefinitely (Signature) (Parent Name)

9 (Cell Phone) (Work Phone) (Home Phone)

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