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703-763-4355 fax 703-763-4365 www.nationalbreastcenter.com PATIENT INFORMATION BREAST CENTER NAME 1 Patient Information LAST FIRST BIRTHDATE AGE ADDRESS NO. FEMALE SOCIAL SECURITY STREET APT. NO. CITY REFERRING DOCTOR MALE MIDDLE STATE ZIP PRIMARY CARE DOCTOR TELEPHONE HOME WORK CELL EMAIL NAME OF SPOUSE OR PARENT OR GUARDIAN OCCUPATION DRIVER’S LICENSE #: EMPLOYER EMPLOYER ADDRESS EMERGENCY CONTACT PRIMARY PRIMARY INSURANCE CARDHOLDER’S NAME 2 CARDHOLDER’S RELATIONSHIP TO PATIENT Insurance Information REFERRAL REQUIRED * POLICY NUMBER CARDHOLDER DATE OF BIRTH CARDHOLDER’S SOCIAL SECURITY # COPAY AMOUNT * REFERRAL OBTAINED *If you are unsure about your specialist co-pay amount or if you are required to have a referral from your primary care doctor to be seen by our office, call the number on the back of your insurance card to verify prior to your appointment. SECONDARY SECONDARY INSURANCE POLICY NUMBER CARDHOLDER’S NAME CARDHOLDER’S SOCIAL SECURITY # CARDHOLDER’S RELATIONSHIP TO PATIENT REFERRAL REQUIRED * COPAY AMOUNT * REFERRAL OBTAINED PLEASE PRESENT ALL INSURANCE CARDS & REFERRALS TO THE RECEPTIONIST 3 Assignment I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled to Surgical Specialists of Northern Virginia, LLC for services rendered by Surgical Specialists of Northern Virginia, LLC. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I hereby assume financial responsibility for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment. I understand that Surgical Specialists of Northern Virginia, LLC and/or the National Breast Center reserve the right to pursue delinquent accounts via third party collection agencies or attorneys. In the event that this account is referred to collections, I agree to be responsible for all costs of collections including attorney’s fees in the amount of 25% of the outstanding balance due at the time of referral to collections. I agree to pay 1 & 1/2 percent per month interest (18% per year), on all accounts which are unpaid after (30) days. I further state that this contract is being executed in Fairfax County, and agree that venue for any action to collect unpaid bills shall be in Fairfax County, Virginia. Signature _________________________________________ Date ________________ BREAST CENTER PRIVACY PRACTICES ACKNOWLEDGEMENT AND CONSENT FORM 703-763-4355 fax 703-763-4365 www.nationalbreastcenter.com I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treat ment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as the business aspects of running the practice on a daily basis. I have read and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. Patient Name: Signature: Relationship to Patient: Name if other than patient: Date: CARE ACCESSS POLICY 703-763-4355 fax 703-763-4365 www.nationalbreastcenter.com BREAST CENTER We have created new office standards that will enable us to offer more timely appointments to you. If you need to reschedule for any reason, please call us so we can accommodate you, and make your spot available to another patient who needs it. Because we are a cancer screening and treatment center, we have developed a cancellation policy to maximize access for urgent appointments and limit wait times for those with the greatest need. $50 Per Missed Appointment Without 24 Hour Prior Notice $100 Per Missed Procedure Without 24 Hour Prior Notice $250 Per Elective Surgery Cancellation Without 1 Week Notice I understand and agree to abide by the above policy. Patient Name (printed) __________________________________ Patient Signature: ________________________________ Date Signed ________________ Responsible Party Name (printed) __________________________________ Responsibily Party Signature: ________________________ Date Signed ________________ Special Reminder Bringing your discs, films, reports, insurance card, and correct referral (if your insurance requires it) can help keep your care treatment plan on track. In most cases, you will need to go the imaging facility to pick up the actual films and reports; imaging facilities usually do not send them in the mail. Be sure you have everything with you the day of your visit and allow at least 2 hours plus your travel time, in case we need to run additional tests for you. We plan to work together with you as a team and we promise to give you our very best at every appointment. 703-763-4355 fax 703-763-4365 www.nationalbreastcenter.com CONTACT ME BREAST CENTER NAME LAST FIRST 1 BIRTH DATE MALE FEMALE It is imperative that we be able to reach you in a timely manner in order to enable us to provide you with the best quality care. As a consideration for our staff and patients, we ask that you provide effective contact information to our office. The best number to reach me: ___________________________ This is my cell home work number other Please only call me at this number between this time window: _______am/pm to _______am/pm I authorize the National Breast Center to leave messages containing the following info at the above number: appointment reminders medical information billing information Other phone numbers that messages regarding appointment reminders and call back requests can be left: ____ ___________ this is my ______________________________ number ____ ___________ this is my ______________________________ number ____ ___________ this is my ______________________________ number I would be happy to receive appointment reminder text messages at this number ___________________ 2 3 I would be happy to receive email correspondence at ___________________________________________ regarding my appointment reminders medical information billing information I designate the following person(s) as an authorized contact for the National Breast Center to speak to about my medical situation. Name: _______________________________________ Relationship to patient: ______________________ Best phone number to reach:__________________ Name: _______________________________________ Relationship to patient: ______________________ Best phone number to reach:__________________ Name: _______________________________________ Relationship to patient: ______________________ Best phone number to reach:__________________ Signature _________________________________________ Date ________________ AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION 703-763-4355 fax 703-763-4365 www.nationalbreastcenter.com BREAST CENTER At times it may be necessary for us to obtain copies of reports and medical records that are related to your condition from other facilities. The following release is used to give us permission to request your records. NAME LAST FIRST BIRTH DATE SOCIAL SECURITY # I request and authorize ___________________________________ to release healthcare information of the patient named above to: National Breast Center 8988 Lorton Station Blvd . 202 Lorton, VA 22079 Fax 703-763-4355 This request and authorization applies to: Healthcare information relating to the following treatment, condition, or dates: ________ _________________________________________________________________________ All healthcare information Other: ____________________________________________________________________ Patient Signature: ________________________________ Date Signed ________________ MEDICAL QUESTIONNAIRE 703-763-4355 fax 703-763-4365 www.nationalbreastcenter.com BREAST CENTER NAME LAST FIRST BIRTH DATE MALE FEMALE PAST SURGICAL HISTORY List All Prior Surgeries and the Year They Were Done 1. _______________________________________________________________________Year__________ 2. _______________________________________________________________________Year__________ 3. _______________________________________________________________________Year__________ 4. _______________________________________________________________________Year__________ 5. _______________________________________________________________________Year__________ 6. _______________________________________________________________________Year__________ 7. _______________________________________________________________________Year__________ 8. _______________________________________________________________________Year__________ 9. _______________________________________________________________________Year__________ 10. ______________________________________________________________________Year__________ MEDICAL HISTORY Please mark any condition you have been diagnosed with: Arthritis Asthma Emphysema COPD Kidney Disease Thyroid Disease ______________________________________________________________________ Diabetes Type I Type II High Blood Pressure Stroke Heart Problems Palpitations Chest Pain Other_____________________________________ HIV / AIDS High Cholesterol Cancer _____________________________________________________________________________ REVIEW OF SYMPTOMS (Please mark all that apply) GENERAL Weight Loss / Gain Fever / Chills Bleed / Bruise Easily Blood Transfusion Anemia URINARY TRACT PROBLEMS Frequent Urination Blood in Urine Prostate Trouble STOMACH PROBLEMS Constipation Diarrhea Nausea / Vomiting Ulcers Heartburn Liver Disease LUNG PROBLEMS Cough Shortness of Breath NEUROLOGICAL PROBLEMS Seizures Head Injury Date: _______________ Type: ___________________________________________ Headaches Numbness / Weakness Location: __________________________________________________ MEDICAL QUESTIONNAIRE 703-763-4355 fax 703-763-4365 www.nationalbreastcenter.com BREAST CENTER NAME LAST FIRST CURRENT MEDICATIONS 1. ________________________________________ 2. ________________________________________ 3. ________________________________________ 4. ________________________________________ 5. ________________________________________ 6. ________________________________________ 7. ________________________________________ 8. ________________________________________ 9. ________________________________________ 10. _______________________________________ 11. _______________________________________ 12. _______________________________________ 13. _______________________________________ 14. _______________________________________ 15. _______________________________________ ALLERGY Reaction (Circle One) 1. ____________________ Mild Moderate 2. ____________________ Mild Moderate 3. ____________________ Mild Moderate 4. ____________________ Mild Moderate 5. ____________________ Mild Moderate 6. ____________________ Mild Moderate 7. ____________________ Mild Moderate 8. ____________________ Mild Moderate 9. ____________________ Mild Moderate 10. ___________________ Mild Moderate BIRTH DATE __________________ Dosage __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ Symptoms Severe _____________________________________ Severe _____________________________________ Severe _____________________________________ Severe _____________________________________ Severe _____________________________________ Severe _____________________________________ Severe _____________________________________ Severe _____________________________________ Severe _____________________________________ Severe _____________________________________ SOCIAL HISTORY Occupation _________________________________________________________________________ Do You Smoke? Yes No Amount ___________________________________________ Do You Drink Alcohol? Yes No Amount ___________________________________________ Do You Use Recreational Drugs? Yes No Amount _________________________________ FAMILY HISTORY (Please Indicate Relationship: ) Cancer High Blood Pressure Diabetes Stroke Heart Disease Thyroid Disease Mother Mother Mother Mother Mother Mother Father Father Father Father Father Father Sibling Sibling Sibling Sibling Sibling Sibling Maternal Grandparent Maternal Grandparent Maternal Grandparent Maternal Grandparent Maternal Grandparent Maternal Grandparent Paternal Grandparent Paternal Grandparent Paternal Grandparent Paternal Grandparent Paternal Grandparent Paternal Grandparent BREAST QUESTIONNAIRE 703-763-4355 fax 703-763-4365 www.nationalbreastcenter.com BREAST CENTER NAME AGE LAST FIRST DATE BIRTHDATE Referring Physician(s): ________________________________________________________________________________ Date of Last Mammogram: ______________________ Location (What facility?) ________________________________ Date of Last breast ultrasound:___________________ Location (What facility?) ________________________________ Current problem(s) / concern(s): Which breast: (mark all that apply) Left Right Both Abnormal imaging Pain Nipple discharge 2nd opinion Lump When noticed?_________________________ By whom?___________________________________ Has it changed? No Yes How?___________________________________________________ Does if vary with your natural menstrual cycle? No Yes How? _________________________ Have you had a biopsy for this? No Yes Results? ____________________________________ Skin Changes ______________________________________________________________________________ Other ____________________________________________________________________________________ Do you perform self breast exams? No Yes How often? ____________________________________________ Do you regularly consume caffiene (coffee, tea, soda, chocolate)? Daily Weekly Other __________________ Have you had other breast problems? No Yes Type of problem? _________________________ Which breast: Left Right Both When? _________________________ Results: __________________________________________________ Have you had breast cancer in the past? No Yes When?______________________________________________ Was it invasive? No Yes Don’t know Treatment:________________________________________________________________________________ Chemotherapy? No Yes Radiation? No Yes Have you ever taken: Tamoxifen Arimidex Femara Other anti estrogens _________________________ When? _____________How Long? ____________________________________________________________ Reason?__________________________________________________________________________________ Are you currently breastfeeding ? Do you still have periods? No Yes Have you breastfed in the last 6 months? No Yes Yes - Start date last menses_________________ No - Age at menopause?______ Natural Surgical Chemo Birth Control Induced Ovaries Removed: one both Hysterectomy - reason for ___________________________________________________ Have you ever taken birth control pills: No Yes How long?: Start (month / year): _________________ Stopped (month/year):__________________ Have you ever taken fertility drugs? No Yes When? ______________ How Long?__________________________ Have you ever taken hormone replacement therapy (estrogen/progesterone)? No Yes What type of hormone replacement therapy?____________________________________________ How long?: Start (month / year): _________________ Stopped (month/year):__________________ Have you ever had genetic testing for breast or ovarian cancer? No Yes Results___________________________________________ FAMILY HISTORY SCREENING QUESTIONNAIRE BREAST CENTER NAME AGE 703-763-4355 fax 703-763-4365 www.nationalbreastcenter.com LAST DATE FIRST BIRTHDATE Are you adopted? Yes No Please list any family history (mother, father, grandparent, sister, brother, aunt, uncle, cousin, niece, nephew) who has or has had any of the listed forms of cancer: No known family history Relationship to You Mother’s side or Father’s side Ex. Aunt_________ ________________ ________________ ________________ ________________ ________________ M M M M M M F F F F F F Type of Cancer (including breast, ovarian, colon, pancreatic) breast breast breast breast breast breast ovarian ovarian ovarian ovarian ovarian ovarian colon colon colon colon colon colon Approximate Age of Diagnosis pancreatic pancreatic pancreatic pancreatic pancreatic pancreatic __65___ _______ _______ _______ _______ _______ What is your nationality (country of origin)? Mother’s side: _________________________________ Father’s side: _________________________________ Ancestry and Clinical History: Western/ Northern Europe Latin American/ Caribbean Near East/ Middle East Ashkenazi Africa Native American Central/ Eastern Europe Asia Other ____________________ Don’t know