Signature Date. No (if yes, name: )

Transcription

1 Louis J. Avvento, M.D. Alexander Zuhoski, M.D. Deepali Sharma, M.D. Sharon Sparacino, ANP-c, Cynthia Cichanowicz, ANP-c Melanie Acierno, DNP, Denise A. Albano, ANP-c 1333 East Main Street Riverhead, NY Tel: (631) Fax: (631) Meetinghouse Lane Southampton, NY Tel: (631) Fax: (631) Patient Registration Forms Name DOB Age Birth Place City State Country Mailing Address Address SS# Home # Work # Cell # Emergency Contact Relationship Home # Work # Cell # Primary Care Doctor Phone # Living Will: Yes No (if yes, name: ) DNR: Yes No Durable Power of Attorney: Yes No (if yes, name: ) Ethnicity: Are you Hispanic/Latino? Yes No Race (circle ALL that apply): American Indian Asian White Black/African American Other Marital Status: Single Married Divorced Domestic Partner Widowed Current / Past Occupation: Medical Insurance Information Primary Insurance ID # Secondary Insurance ID # Name of insured if other than patient DOB Drug Prescription Information Plan Name ID# PCN# BIN# Tel no. Mail Order Pharmacy: Tel no. Local Retail Pharmacy: Tel no. Authorization: I hereby give authorization for Eastern LI Hematology/Oncology to furnish information to insurance carriers concerning my illness/accident and irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially responsible for all charges whether or not they are covered by my insurance. Signature Date pg. 1

2 PATIENT ACKNOWLEDGEMENTS PLEASE READ AND INITIAL EACH SECTION APPOINTMENT CHECK IN To ensure that Eastern LI Hematology Oncology has accurate up-to-date information please understand that our receptionists will ask you at EVERY appointment to provide the name of your insurance, pharmacy, primary care physician and any other pertinent information as deemed necessary. In order to update/confirm your current medications, you will be asked to bring your medication bottles to every appointment. You may be also be asked to complete forms that have previously have been completed. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) I have read and understand the Privacy Notice outlining Eastern LI Hematology/Oncology s responsibilities and my rights under HIPAA. A copy of this notice is available at or provided upon request from the patient. online at INSURANCE (existing/changing) and REFERRALS It is up to you to know your insurance coverage. For questions regarding your coverage/responsibilities, you should contact a customer service representative. The number can usually be found on the back of your insurance card. You should know what laboratory, radiology, home care agency and referral requirements that are set by your insurance company. This office will not take responsibility for obtaining that information. We REQUIRE a minimum of 2 business day s notification when you are changing insurances. Please contact our billing department with your new insurance information. If we are not properly notified, referrals and/or pre-certifications may not be requested/received and charges accrued will be the patient s financial responsibility. INSURANCE CO-PAYMENTS/COINSURANCES/DEDUCTIBLES Co-payments are to be collected upon checking in with our front desk staff. No exceptions will be made unless arrangements have been made prior with our billing department and/or managers. Insurances that apply coinsurances/deductibles will require a credit card authorization on file unless arrangements are made prior to appointment with the Practice Administrator, Lynn Kay Winters. DRUG CO-PAYMENT ASSISTANCE PROGRAMS Our office may investigate manufacturer s co-pay assistance programs for some medication(s) commonly prescribed at Eastern LI Hematology/Oncology. You hereby authorize Eastern LI Hematology Oncology to apply on your behalf. PT INITIALS MISSED APPOINTMENTS Appointments that are missed for any reason aside from medical emergencies without 2 business day s notice are subject to a 25$ MISSED APPOINTMENT CHARGE. Any such charges are due and payable upon receipt of notice. PT INITIALS I acknowledge that I have read and understand all of the above. Patient Signature Date pg. 2

3 AUTHORIZATION FOR MEDICAL INFORMATION TO BE GIVEN WHO MAY WE GIVE INFORMATION TO IN REGARDS TO YOUR CASE? We take patient confidentiality very seriously. In order to ensure that our staff does not give out information to individual(s) that you have not approved, we ask that you fill out the section below. Only these individuals will be apprised of your case history and progress. Name/Relationship Primary Contact # Secondary Contact # PLEASE CHECK AND INITIAL IF YOU DO NOT WISH ANYONE TO HAVE INFORMATION IN REGARD TO YOUR MEDICAL CONDITION. THIS CAN ONLY BE CHANGED IN WRITING BY YOU. _ TO ENSURE CONTINUITY OF CARE, PLEASE SEND ALL PROGRESS NOTES, TEST RESULTS TO: Doctor Name Address Phone Fax PATIENT SIGNATURE DATE pg. 3

4 MEDICATION / ALLERGY LIST (attach additional sheets if necessary) Name Pharmacy MEDICATIONS Name of Medication (attach additional sheets if necessary) Dose Frequency Name of Drug (attach additional sheets if necessary) DRUG ALLERGIES Reaction Height: Weight: SMOKING STATUS: NEVER SMOKED FORMER SMOKER, QUIT # YEARS AGO CURRENT EVERYDAY SMOKER ALCOHOL USE: FREQUENT OCCASIONAL NEVER CURRENT SOME DAYS SMOKER CURRENT IV DRUG USE: PAST IV DRUG USE: TRANSFUSION HISTORY FREQUENT OCCASIONAL NEVER FREQUENT OCCASIONAL NEVER pg. 4

5 MEDICAL HISTORY TEST DATE OF TEST NAME OF FACILITY MAMMOGRAM PAP/GYN EXAM COLONOSCOPY ENDOSCOPY PSA CHEST XRAY PET SCAN MRI CT SCAN BLOODWORK OTHER PERTINENT MEDICAL HISTORY: TYPE DATE SURGICAL HISTORY: TYPE DATE ADDITIONAL INFORMATION YOU WOULD LIKE YOUR PHYSICIAN TO KNOW: pg. 5

6 FAMILY CANCER HISTORY FORM Please provide as much information as possible. You may not know all of the information or specific dates. Any area that you are unsure about, please mark with a question mark (?) next to it. If more space is needed, please attach a separate sheet of paper. Family members with cancer diagnoses Relationship to you (i.e.: mother, son, niece, etc) Current Age (indicate if deceased) Type of cancer Age when diagnosed with cancer pg. 6