489 Union Avenue Bridgewater, NJ Tel (732) Fax (732)

Transcription

1 489 Union Avenue Bridgewater, NJ Tel (732) Fax (732) LOUIS J. ARNO, M.D, FACP, FCCP NEHAL L. MEHTA, MD, FCCP,D-ABSM PRASHANT B. PATEL, MD Dear Patient: Welcome to Respacare! We are sending you our Patient Information, History, Medication and HIPPA Privacy forms for you to fill out before your office visit. DUE TO HIGH PATIENT VOLUME, YOUR APPOINTMENT TIME MAY BE EFFECTED IF THIS PAPERWORK IS NOT COMPLETE WHEN YOU ARRIVE FOR YOUR OFFICE VISIT. Be sure to bring these COMPLETED FORMS with you for your visit, as well as: YOUR INSURANCE CARD (S) LICENSE REFERRAL (IF REQUIRED) RECENT (CAT SCAN, X-RAYFILMS, LAB REPORTS & EXTERNAL SLEEP STUDY) REPORTS ARE THE RESPONSBILITY OF THE PATIENT FILMS AND REPORTS MUST BE BROUGHT IN FOR THIS APPOINTMENT. In addition, it is very important that you arrive 15 minutes prior to your appointment time to allow our staff to update your patient record. For your convenience, we have also enclosed directions to our office. Sincerely, The Staff at Respacare Appointment Scheduled For: Date: Time: With:

2 Louis J. Arno, MD Nehal L. Mehta, MD Prashant B. Patel, MD 489 Union Avenue Bridgewater New Jersey Phone (732) Fax (732) Louis J. Arno, MD Nehal L. Mehta, MD Prashant B. Patel, MD DIRECTIONS BRIDGEWATER OFFICE UNION AVENUE Via I-287 North: Exit 13B (Somerville) Route 28 (West). Travel West on Route 28 slightly less than one mile to Respacare at 489 Union Avenue (building is on the right). Via I-287 South: Exit 13 (Somerville) Route 28 (West). Travel West on Route 28 slightly less than one mile to Respacare at 489 Union Avenue (building is on the right). Via Route 22 West: Route 22 West passing under I-287, exit at sign for Manville/Finderne Avenue, bearing right onto Finderne Avenue and follow to next light at top of the hill. Turn left onto Route 28, Union Avenue. Respacare will be on the left. Via Route 22 East: Route 22 East from White House area, make a right onto Finderne Avenue at Kemper Kia. Follow Finderne to light at top of the hill. Turn left onto Route 28 (Union Avenue). Respacare will be on the left. ***************************

3 PLEASE FILL OUT COMPLETELY AND BRING WITH YOU TO YOUR APPOINTMENT PATIENT INFORMATION Thank you for choosing Respacare! In order to serve you properly, we need the following information. All information will be confidential. Date: Patient Name: Address: City: State: Zip: Date of Birth: Home Phone ( ) Cell Phone ( ) Address SSN: - - Gender M or F Ethnicity: Hispanic or Latino Not Hispanic or Latino Please Cir cle One: Minor Single Married Divorced Widowed Separated Race: Language (Please Check One): English Spanish Indian Other Employer: Work Phone: ( ) If Patient is a student, name of School/College: City: State: Who may we thank for referring you? Primary Care Physician: Phone: ( ) Office Location: City: State Zip Person to contact in an emergency: Phone: ( ) Alt Phone: ( ) Relationship: Address:

4 Pharmacy Name Location: Pharmacy Phone ( ) Pharmacy Fax ( ) Patient Name: Date of Birth: / / Responsible Par ty Name: Relationship to Patient: Address: City: State: Zip: Employer: Work Phone: ( ) Date of Birth: Is this person currently a patient at our office (Circle) Yes or No Primary Insurance Information Name of Insured: Relationship to Patient: Date of Birth: SSN#: - - Employer: Employer Address: City: State Zip: Insurance Co.: ID#: Group #: Ins. Address: City: State: Zip Secondary Insurance Information Name of Insured: Relationship to Patient: Date of Birth: SSN#: - - Employer: Employer Address: City: State Zip: Insurance Co.: ID#: Group #: Ins. Address: City: State: Zip ********************************************** I authorize the release of any information concerning my (or my child s or guardian s) healthcare, advice and treatment provided for the purpose of evaluation and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me, directly to my doctor. Patient Signature: Date: Parent/Guardian Signature: Date:

5 MEDICATIONS Patient: Birthdate: / / Home Phone: ( ) - Work Phone: ( ) - Pharmacy: Phone: ( ) - Allergies: DATE Rx M EDI CATI ON DOSAGE PRESCRI BED BY:

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8 Louis J. Arno, MD Nehal L. Mehta, MD Prashant B. Patel, MD 489 Union Avenue Bridgewater New Jersey Phone (732) Fax (732) Louis J. Arno, MD Nehal Office L. Mehta, and Financial MD Prashant Policies B. Patel, MD If we do not participate with your insurance: We will collect the full fee on the day of your appointment. You will be provided with a statement, which you may submit to your insurance company. Co-Payments: Co-Pays are due at the time of your visit. Returned checks: A fee of $25.00 will be charged for any returned checks. Disability Forms: You can provide us the appropriate forms that need to be completed by the doctor. A $20.00 fee will be charged for EACH form. Cancelled Appointment Char ge: In order to optimize scheduling, we require at least 24 hours in advance of your appointment if you need to reschedule. If you cancel an appointment with less than 24 hours notice, a fee of $25.00 will be charged to you. M issed Appointment Char ge: A $25.00 fee will be charged for any missed appointments. Privacy Notice: If you page any of the doctors through the answering service, please make sure to inactivate your anonymous call blocking system. The doctors at RespaCare reserve the right to the privacy of their personal phone numbers. I certify that I have read the above statements, and I understand that I am fully responsible for all charges for services rendered including co-pays, co-insurance, deductibles, and any services not covered by my insurance. Name Signature Date

9 Louis J. Arno, MD Nehal L. Mehta, MD Prashant B. Patel, MD 489 Union Avenue Bridgewater New Jersey Phone (732) Fax (732) Acknowledgement for the Use and Disclosur e of Health I nfor mation Louis J. Arno, MD Nehal L. Mehta, MD Prashant B. Patel, MD The department of Health and Human Services has established a Privacy Rule to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients consent for the uses and disclosure of health information about the patient to carry out treatment, payment, or health care operations. As our patients, we want you to know that we will respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We make every effort to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest. I, have had full opportunity to read and consider the (Please Print Your Name Here) contents of RESPACARE Notice of Privacy Practices. I understand that, by signing this form, I am acknowledging the use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations. Signature Date **** If a personal representative on behalf of the patient is signing this acknowledgement, complete the following: Personal Representative s Name Relationship to Patient Note: Anyone wishing a copy of Section 1 Uses and Disclosures of HIPPA, please advise the receptionist.

10 489 Union Avenue Bridgewater, NJ Tel (732) Fax (732) LOUIS J. ARNO, M.D, FACP, FCCP NEHAL L. MEHTA, MD, FCCP,D-ABSM PRASHANT B. PATEL, MD PERMISSION A) I hereby give permission for RESPACARE to release information about my health or have the doctor speak with: Print Name Relationship to Patient Print Name Relationship to Patient B) In addition, messages pertaining to my treatment may be left on: (Please check all that apply: ) Home Phone Cell Phone Work Phone Patient s Name (Please Print) Date of Birth Patient s Signature Date