Download New Patient Forms copy - Premier Heart and Vein Care

Patient Intake Information
PATIENT INFORMATION
Name:_________________________________________________________
Date of Birth ___________________
Address:__________________________________________________
Sex:
City, State, Zip: ______________________________________________
Social Security Number __________________
M ____ F____
Home Phone: ____________________________________________________ Is it OK to leave message? Y N (Circle One)
Cell Phone: ______________________________________________________ Is it OK to leave message? Y N (Circle One)
The best number to reach you: ___Home
___Cell Email _________________________________________
May we add you to our mailing list? ___________
Marital Status
____Married
____Single
How did you hear about us?
____Divorced
____Widowed
____Race
____Ethnicity
Referring Physician______________________________________________________
Primary Care Physician___________________________________________________
PATIENT EMPLOYMENT INFORMATION
____Employed
____Retired
____Unemployed
EMERGENCY CONTACT
____ Self Employed
Name _______________________________
Employer Name________________________________________________
Address______________________________
Employer Address______________________________________________
_____________________________
City, State, Zip ________________________________________________
Phone
Employer Phone_______________________________________________
Relationship _________________________
_____________________________
PRIMARY INSURANCE
SECONDARY INSURANCE
Insurance Co. Name______________________________
Insurance Co. Name ____________________________
ID Number______________________________________
ID Number ___________________________________
Group/Policy Number______________________________
Group/Policy Number___________________________
Subscriber Name__________________________________
Subscriber Name_______________________________
Subscriber Phone_________________________________
Subscriber Phone_______________________________
Subscriber Employer_______________________________
Subscriber Employer____________________________
Subscriber Date of Birth_____________________________
Subscriber Date of Birth_________________________
Subscriber SSN____________________________________
Subscriber SSN________________________________
1
Premier HeartCare Patient Intake Form Page 2
INSURANCE AUTHORIZATION AND ASSIGNMENT
(Please read and sign)
I attest that the information I have given here is correct and true to the best of my knowledge. I hereby
assign benefits to be paid directly to the doctor and/or Premier HeartCare, and authorize Premier HeartCare
to furnish information regarding my illness to my insurance carrier. I have been informed of HIPPA
Patient Privacy Rules. I understand that I am financially responsible for any amount(s) not paid by
my insurance company. I acknowledge receipt of the HIPPA Privacy Policy.
____________________________________________________
Patient/Patient’s Representative Signature
___________________
Date
2
CONDITIONS OF SERVICE
FINANCIAL POLICY
HIPAA POLICY ACKNOWLEDGMENT
Thank you for choosi ng Premi er Heart and Vein Care. This document represents our
established Conditions of Service that will be used to resolve any issues or disputes
pertaining to cardiac and vei n care services rendered by the practice. We ask you to read,
sign, and return this agree ment prior to any treatment.
C ONSENT TO TREATMENT: The patient identified below consents to diagnostic and therapeutic
cardiac and vein care evaluations and treatment, which may be performed or assisted by Dr Kenneth
Stevens and his staff. These evaluations and treatments may include, but are not limited to, initial
evaluation or consultation, history and physical examination, and periodic follow up. Cardiac
assessments include electrocardiograms, stress testing, echocardiograms, blood work, and nuclear
testing. Vein assessments and treatments include lower extremity venous ultrasound study, infiltration
of tumescent local anesthesia, radiofrequency or endovenous laser ablation, ultrasound-guided
sclerotherapy, Veinlite sclerotherapy, and/or conservative vein therapy. Appropriate referrals will be
facilitated as well to optimize patient care as well for services unavailable within the practice.
PAYMENTS: Premier Heart and Vein Care participates with many insurance plans as a convenience
to our patients. Your insurance company determines your co-payment and/or deductibles. Our
contracts require that all medical facilities collect these fees, to ensure the insurance policy is
enforced. Please understand that payment of your bill is considered in part the responsibility of the
patient. Payment, according to the policies below, is due at the time of service. We accept cash,
checks, Care Credit, Visa, American Express, and Master Card. "Returned Checks" will be charged a
$50.00 fee and if not paid within 10 days will be referred to San Luis Obispo County Court for legal
action. It is your responsibility to contact us as soon as you are aware that your check has been
returned without payment. Also if you write a dishonored check you will be required to pay via cash
or credit card.
PATIENTS WITH INSURANCE: In order for us to correctly bill your insurance company we will
need a copy of your health plan ID card at the time of your visit. You are responsible for payment of
these items not payable by your insurance plan including but not limited to: deductibles, co-pays, coinsurances and non-covered services. If your insurance requires prior authorization for treatment or
procedures, we will be happy to assist you; however it is the patient’s responsibility to insure
authorization is obtained. For services deemed “not medically necessary” by your insurance plan you
will be required to read and sign a Patient Responsibility Agreement with this Office each time you
request those types of treatment. Co-payments are required to be paid at the time of your office
visit according to our agreement with your health plan. Any “co-insurance” amount you owe for
rendered services are due and payable upon receipt of our bill. Accounts not paid within thirty (30)
days will be considered delinquent and must be paid prior to scheduling your next office visit.
PATIENTS WITHOUT INSURANCE: Payment in full is due at the time of service. If you are a
Phlebology (Premier Vein Care) patient and you are unable to pay the entire balance at the time of
service, we offer another payment option under our agreement with Care Credit, a patient payment
finance company. We will not be able to perform any treatment or procedure without receipt of full
payment at the time of your visit.
(Conti nued)
3
MEDICARE: Our office will submit your Medicare charges to Medicare and your secondary insurance if
applicable. You are responsible for deductibles, co-pays and any non-covered services for which we have
on file a signed Advanced Beneficiary Notice!""
MISSED APPOINTMENTS: Office Visits, Follow-ups and Ultrasound Testing: Please notify this
office at least 48 hours in advance of any cancellations. If not notified you will be charged a
$25.00 fee. Patients having any procedure (including, but not limited to vein ablation and cardiac
testing) a 48 hour notification are required for cancellation or to reschedule an appointment. If not
notified a $100.00 fee will be charged. Cosmetic Procedures: (including but not limited to
Sclerotherapy) will be charged a fee of $50.00 if not given at least 48 hour notice. Please help us
serve you and all of our patients better by keeping scheduled appointments; 3 unapproved
cancellations will result in dismissal from the practice.
PERSONAL VALUABLES: It is understood and agreed that Premier Heart and Vein Care shall not
be
held liable for the loss, theft or damage to any personal property left behind in any dressing room,
exam
or treatment room including but not limited to: cash, coin, checkbooks, jewelry, documents,
eyeglasses, hearing aids or other personal property.
C ONSENT TO PHOTOGRAPH/VIDEO TAPING/TEACHING: Premier Heart and Vein Care is
permitted to take pictures of the medical or surgical progress involving vein care. The patient
consents to photography and/or videotaping during medical or surgical procedures and the use of
same for scientific, educational or medical research purposes. The patient further consents to routine
photo documentation related to patient care. There may be other Physicians and Technicians
observing your procedure (with your permission) in order to enhance their medical education and
training as we are a teaching facility.
SEVERABILITY: If any terms or conditions of this agreement are held by a court of law to be
invalid or
Unenforceable, then this agreement, including all of the remaining terms and conditions, will remain
in full force and effect as if such invalid or unenforceable term or condition had never been included.
My signature below acknowledges that I have received a copy of this document and accept its terms.
RELEASE OF INFORMATION: I authorize Premier Heart and Vein Care to release my
insurance
carri er(s) and its ag ents and/or my Medigap insurer any information ne eded to determi ne
benefits or benefits payabl e to Premier Heart and Vein Care for related services.
DEFAULT: I understand that regardless of insurance coverage, that if after default my
account is
placed in the hands of an attorney or collection agency for collection, the undersigned
agrees to pay
for any unpaid balance and all attorney and/or collection fees.
Thank you for taking the time to read and understand our Financial Policy. Our practice believes
good communications is essential in our relationship with our patients. Please let us know if you have
any questions or concerns before signing below. Your signature indicates that you have read this
policy and understand and agree to its terms.
_________ I have read and agree to the Financial Policy and Release Information paragraphs
Initial
stated above
_________ I have been offered/given a copy of Premier Heart/Vein Care’s HIPAA Policy and
Patient's
Initial
Rights and Responsibilities and I have been given the opportunity to ask questions.
__________________________ ___________________________ _________________
Signature
Print
Date
4
NEW PATIENT HISTORY AND PHYSICAL FORM
(Please complete and bring to your first visit)
Name of Patient:
Date of visit:
Last
First
Age:
Date of Birth:
M.I.
Sex: M
F
Height:
Weight:
lbs.
What medical problem or condition are you here to have evaluated?
Current Medications: (please list all prescriptions, non-prescription medications and nutritional supplements)
CURRENT MEDICATIONS
DOSE (Strength)
SCHEDULE (How many & times per day)
HOW LONG HAVE YOU TAKEN?
Example: Lopressor
50 mg
1 tablet, two times a day
6 months
Drug/Food Allergies:
Are you allergic to:
Yes
No
Please list all allergies to medications and other substances. Describe reaction they cause
Any medications
Iodine, fish or shellfish
X-ray dye or IV contrast
Can you tolerate aspirn?
Social History
Do you have:
Yes
No
High blood pressure................................................................................................................................
Diabetes.................................................................................................................................................
Controled with:
Insulin, How long:
Pill
Diet
High cholesterol......................................................................................................................................
Family history of heart or vascular disease..............................................................................................
A history of Rheumatic Fever or Scarlet Fever.........................................................................................
Do you now or have you ever smoked tobacoo products..........................................................................
Cigarettes: # of packs per day:....................................................................
#of years:
Cigars:....................................................................................................................................................
Pipes:......................................................................................................................................................
When was your last cigarette, cigar or pipe?............................................................................................
5
Do you:
Yes
No
Do you drink alcohol on a regular basis?.................................................................................
if no, did you drink heavily in the past?....................................................................................
If yes, how much do you typically drink in one week?.............................................................
Do you use recreational drugs?...............................................................................................
Have you ever been treated for substance abuse?.................................................................
Diet:
Balanced
Low fat low cholesterol
Low salt
No special diet
Other, please describe:
Activity Level: which of the following best describes your level of physical activity both in your daily life and your leisuretime
Exercise strenuously on a regular basis
Exercise moderately on a regular basis
Exercise on a occasional basis
Have You Ever Had Any of the Following
Do not regularly exercise, but have an active lifestyle
Have difficulty accomplishing light chores of daily life
Require assistance to accomplish self-care
Yes
No
Date or Year
Place (Hospital or City)
Complications/Problems
Surgeon
Place (Hospital or City)
Complications/Problems
Exam by a Cardiologist (Heart Doctor)
Heart Catheterization or Angiogram
Coronary Angioplasty (PTCA/Ballon/Stents)
Exercise Stress Test (Treadmill)
Echocardiogram (Ultrasound of the Heart)
Pacemaker/Difibrillator
Open Heart Surgery
Previous Operations/Procedures:
Year
Reason for other Hospitalizations (Non-Sergical Admissions)
Year
Physician
Please List Any Other Medical Illnesses, Any Other History of Cancer or Chronic Conditions
Place (Hospital or City)
How Long Have You Had This
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If you are scheduled for surgery or a hospital stay, please answer the following questions:
Have you or a blod relative had any problems with anesthesia:
Yes
No
If yes, please describe:
Please answer the following questions:
Review of Systems
EAR/NOSE/THROAT
KIDNEYS/URINARY TRACT
Rashes, psoriasis or dermatitis
Loss of Hearing
Kidney disease or failure
Non-healing sores or skin ulcerations
Hearing aids?
SKIN
Yes
No
History of kidney dialysis
Ringing in the ears
What year:
Frequent or severe nose bleeds
Kidney stones or infection
Wear glasses
Frequent sinus infections
Pain or burning with urination
Wear contact lenses
Dentures
Dribbling or incontinence
EYES
Permanent blindness in either eye
Cataracts
Glaucoma
HEART
Multiple trips to the bathroom to urinate
NERVOUS SYSTEM
at night
Frequent headaches or migraines
Blood in urine during past year
Epilepsy or seizures
Enlarged prostate
date of last seizure
Heart attack, What year (s):
Depression
Chest discomfort/angina
Nervous disorder
Thyroid disorder
with physical activity
Specify:
Gout
Chest discomfort/angina at rest
Shortness of breath with exertion
METABOLISM/ENDOCRINE
Recent weight gain or loss (>10lbs)
CIRCULATION
MUSCLES/BONES/JOINTS
Shortness of breath at rest
Discoloration of feet or legs
Require more than one pillow at
Pain in legs or buttocks with exercise
Arthritis or other joint disease
night to breathe well
Sores or ulcers on feet or legs
Chronic back trouble
Heart failure or “fluid on lungs”
Blood clot in artery
Curvature of the spine (scoliosis)
Palpitations, racing or pounding
Blood clot in leg vein
heart beat
Ankle or leg swelling
REPRODUCTIVE
Pauses in the heart beat
Phlebitis of leg veins
Are you or might be pregnant?
Previously diafnosed heart rhythm
Sudden visual disturbances in either
disturbance
eye
Heart murmur
Weakness or paralysis of one side of
Mitral valve prolapse
the body
REPRODUCTIVE
Temporary speech loss or difficulty
Have you had a vasectomy?
BLOOD
talking
Bleeding or bruising tendency
Stroke
Blood disorder
Dizziness light-headedness or
Specify:
“black out spells”
Previous blood transfusion
Aneurysm of any blod vessels
Recent fever
“Mini-strokes” or TIA’s
Yes
(for Women)
No
Date (or year) of last period:
Yes
(for Men)
No
Erectile Dysfunction?
Yes
No
History of hepatitis or other
communicable disease
LUNGS
Asthma or wheezing
STOMACH/INTESTINES
Recent bronchitis or chest cold
Stomach ulceror peptic ulcer
Pneumonia
Frequent heartburn or indigestion
Emphysema
Liver disease or jaundice
Tuberculosis
Whar year:
Chronic cough
Frequent diarrhea
Coughing up blood
Chronic constipation
Exposure to asbestos
Dark, tarry stools
Blood clot (embolus) to lungs
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Family History
Relation
Age
Age at
Death
Cardiac History
Father:
Mother:
Sister:
Sister:
Brother:
Brother:
Please list which family members (blood relatives) have experienced these conditions
Heart Attack:
Sudden Death:
Stroke:
Age:
Aneurysm:
Age:
Diabetes:
Age:
Cancer:
Age:
High Blood Pressure:
Age:
High Cholesterol:
Age:
Heart Failure:
Age:
Arteriosclerosis:
Age:
(hardening of the arteries)
Do you have any other special concerns or additional infomation we should be aware of regarding your care:
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members
of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Patient signature
Date
8
Medical Records Release
I hereby authorize Premier HeartCare to RELEASE or OBTAIN my medical record information as specified below:
Patient Name_______________________________________________________ DOB______________
Premier HeartCare may RELEASE copies of my
medical records to:
Premier HeartCare may OBTAIN copies of
my medical records from:
_______________________________________
Physician/Institution Name
_______________________________________
Physician/Institution Name
_______________________________________
Address
_______________________________________
Address
_______________________________________
City, State, Zip
_______________________________________
City, State, Zip
_______________________________________
Phone/Fax Number
_______________________________________
Phone/Fax Number
INFORMATION TO BE RELEASED: (Please check
all that apply)
MEDICAL RECORDS REQUESTED BY
PREMIER HEARTCARE SHOULD BE
SENT TO:
_____Office /Consult Notes
____ Radiology/Imaging Studies (CT, MRI, Nuclear
Medicine, Echocardiography, X-Ray, etc.)
____Lab Results
____Immunization Records
3231 South Higuera Street
San Luis Obispo, CA 93401
Phone 805-540-3333
Fax 805-540-3344
___Other_________________________________
Information to be excluded from this release:
____________________________________________________________________________________.
(please list specific information to be excluded from release if applicable)
This information will be used for the following purposes: Treatment, Payment (e.g. insurance companies), and Routine
Healthcare Operations.
This authorization is valid for one year from the date of this authorization or until ___________________.
(insert date here)
______________________________________
Signature of patient or patient’s representative
___________________
Date
______________________________________
Printed name of patient or patient’s representative
___________________
Relationship to patient
9
A.
Venous Health History Form
Patient please complete questions 1-12
Patient Name: ____________________________
Date of Birth: ______________
Directions: Please answer the following questions. Provide estimates for date of occurrence.
Past Medical History
1. Have you ever had vein stripping surgery
Yes
No
If yes, when and which leg? _______________________________________
Yes
No
2. Have you ever had vein injections?
If yes, which leg and where on the leg? _____________________________
Yes
No
3. Have you ever had a blood clot?
If yes, which leg and when? _______________________________________
Yes
No
4. Have you ever had phlebitis?
If yes, which leg and when? _______________________________________
Family History
Does anyone in your family have (or used to have) varicose veins, spider veins, leg ulcers or swollen legs?
Father
Yes
No
Yes
No
Mother
Yes
No
Brother(s)
Yes
No
Sister(s)
Yes
No
Other
1. Do you experience any of the following in your legs?
Yes During activity or prolong standing
Aching/pain?
Yes During activity or prolong standing
Heaviness?
Tiredness/fatigue? Yes During activity or prolong standing
Yes During activity or prolong standing
Itching/burning?
Yes During activity or prolong standing
Swollen ankles?
Yes During activity or prolong standing
Leg cramps?
Restless legs?
Yes During activity or prolong standing
Yes During activity or prolong standing
Throbbing?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
VAS Scale -Rate the intensity of pain_____________ Persistent
No
No
No
No
No
No
No
No
Yes
LT / RT leg
LT / RT leg
LT / RT leg
LT / RT leg
LT / RT leg
LT / RT leg
LT / RT leg
LT / RT leg
Both legs
Both legs
Both legs
Both legs
Both legs
Both legs
Both legs
Both legs
No
Yes
No
2. Have your veins gotten worse in recent months?
Describe: ________________________________________________________________
Yes
No
3. Do you take any medication for pain (i.e., Advil, Motrin)
If yes, what medication(s) do you take and how many times/mgs per day? _______________
_________________________________________________________________________
REF VN20-04-F 06/07
For Internal Use Only- Do Not Submit Checklist to Payor
10
Yes
No
4. Do you elevate your legs to relieve discomfort?
If yes, how long per day do you elevate and does it provide relief?______________________
Venous Health History Form (cont.)
5.
Do you exercise?
Yes
No
If yes, what kind of exercise and how often? ________________________________________
6.
Do you wear prescription compression stockings?
Yes
No
If yes, what type and gradient? How long have you worn them? _________________________
___________________________________________________________________________
If yes, what is the name of the physician who prescribed your compression stockings and when
were they prescribed? _______________________________________________________
7.
Do you wear light support hose (i.e., Sheer Energy)?
If yes, do they provide relief?
8.
Yes
No
Do you have any problem walking?
If yes, describe how it interferes with your activities of daily living, which activities? (worse at night,
after standing/sitting long periods or after exercise) ______________________________________
_____________________________________________________________________________
9.
What type of work do you do? ____________________________________________________
How long do you stand (hours per day) at work? ______________ At home? _____________
Describe how your symptoms are/ if interfering with your essential job function of your specific
occupation, which activities: (inability to walk or stand for long hours)_______________________
_____________________________________________________________________________
10.
Yes
No
Have you ever had any test(s) done on your veins?
If yes, when and what type of test and where on the leg? __________________________________
_____________________________________________________________________________
11.
Were you diagnosed with saphenous vein reflux?
12.
Name of referring Physician and how long have you been under his care for treatment of this
condition?
_____________________________________________________________________________
Yes
Yes
No
No
Patient Signature: ___________________________________________Date:______________________
PATIENTS: Please stop here. The physician may go over additional questions with you.
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