Dear Patients and Prospective Patients:

Transcription

1 Dr. Ella Pantazis Annapolis Rd #221 GlennDale MD Fax: Dear Patients and Prospective Patients: Our office is excited to let you know that we are transitioning to Electronic Health Record-keeping and expanded Electronic processing of Insurance Claims! Although it is a big undertaking, we are confident that it will help us to keep precise, complete health records and give us a more efficient means to provide your other health care professionals the information needed to coordinate your health care needs. Of course, your personal and health information will never be shared without your specifically requesting or giving permission for us to do so! You may complete these forms the next time you come to our office OR you are free to print and complete them now and either fax or them to us! This will allow us to enter you into the new Electronic Health Record software and you will be good to go when you have your next appointment with us. You will find a one page form which requests all the information we need to process your insurance claim efficiently. We are happy to submit claims to all insurance companies with whom we participate, including Medicare. The remaining pages are basic patient demographic and health information. You will notice a few questions regarding specific health conditions. Your answers to these will help us to better understand your general health and how we might further support your body s ability to heal and recover. In addition, this information will help create a more complete health record, especially in the event that you should request that this information be provided to your other health professionals. Thank you, in advance, for completing the registration, insurance, and health information forms as best as you are able. Feel free to ask a staff member for assistance if you are having any difficulty. Very sincerely, Dr. Ella Pantazis and staff

2 Ella E. Pantazis, D.C Annapolis Rd. #221 GlennDale MD PATIENT NAME: DATE OF BIRTH: Is condition due to an accident? Yes No Date Who is responsible for this account? Relationship to patient: Insurance Information: Patient Employer/school: Employer address: Employer phone: Spouse s Name: Spouse s date of birth: Spouse s SSN: (if your insurance coverage is under your spouse s name and/or employer) Insurance Co Group# Patient covered by another insurance? Subscriber s Name DOB SSN Relationship to patient Second insurance: Assignment and release: I certify that I, and/or my dependent, has insurance coverage with and assign directly to Dr. Pantazis all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submission. Signature of patient/parent or guardian Date relationship Were you referred to our office? By whom?

3 Ella E. Pantazis, D.C Annapolis Rd. #221 GlennDale MD Patient Information/Health History Name: Today s Date: Patient Title: (circle) Mr. Mrs. Ms. Miss Dr. Prof. Rev First Name: Nick Name: Last Name: Middle Name: Address 1: City State: Zip: Primary Phone: Secondary Phone: Mobile Phone: Preferred Contact Method: (please circle) Prim. Phone Second. Phone Mobile Phone Date of Birth: Age Gender SSN: Marital Status: (circle) single married partnered separated divorced minor Employment Status: (circle) employed ft/pt student other retired self employed Race: (circle) white black/african American Hispanic Other OR I choose not to specify Preferred Language: (circle) English Spanish American Sign Language Other: OR I choose not to specify Verification question and answer: (this is your secret question. If you call or and ask for records to be produced or other confidential information, we will be able to verify that it is really YOU and this will help us protect your confidential information.) Circle ONE of the following, and then provide the answer to that question: What is the name of your favorite pet? In what city were you born? What is your favorite movie? What is your mother s maiden name? What high school did you attend? On what street did you grow up? What was the make of your first car? When is your anniversary? What is your favorite color? Answer:

4 Patient Information page 2 Name: Health Questions: 1. Do you currently smoke tobacco of any kind? (circle) yes former smoker never If yes everyday? Sometimes? If yes, what is your level of interest in quitting smoking? 0 (none) to 10 (very) 2. Has your physician diagnosed you with Hypertension presently? Any history of stroke or TIA s? vertigo Medication controlled? Yes/ No 3. Has your physician diagnosed you with Diabetes presently? If yes, (circle) Type I Type II If yes, was your blood lab-work test for hemoglobin A1c > 9.0%? (circle) Yes No Not Sure 4. Have you had an X-Ray or CT or MRI of your spine in the past 28 days? If yes, which region of your spine? Neck Low Back If more than 28 days, date of most recent MRI/CT/Bone Scan: 5. Caffeine intake/cups per day Stress: 6. Are you under a physician s care for any other health problems? If yes, describe: Alcohol/Drug dependence Anorexia/Bulimia Breast/Genital issues Cancer Epilepsy/Neurological issues Thyroid/Endocrine Autoimmune Rheumatological Arthritis Stomach/Intestinal Infections, such as-lyme Cardiac Medications: Current Medications and dosage, if known. If NO MEDICATION: check here

5 Patient Information page 3 Name: Allergies: List any known allergies you have had to any medications, foods, or other If NO MEDICATION ALLERGIES KNOWN: check here Primary Physician s Name: phone: What is your primary reason for seeing us today? Patient signature: (or parent/guardian, if patient is a minor) Date: In Case of Minor aged patient: I, give permission to Dr. Ella (name of parent or guardian) Pantazis to evaluate and treat my minor aged child. (name of minor aged patient) (signature of parent/guardian) (today s date)