Download Infectious Diseases Associates of Fort Lauderdale

PATIENT’S NAME:
DATE OF BIRTH:
REFERRING PHYSICIAN
TELEPHONE (
)
CURRENT COMPLAINTS:
HIV POSITIVE SINCE:
ALLERGIES TO DRUGS:
CURRENT MEDICATIONS:
CURRENT COMPLAINTS: (Please check appropriate response)
YES
NO
Anxiety
Blood in stool
Diarrhea
Difficulty swallowing
Dizziness/Fainting
YES
NO
Easy bruising/bleeding
Fatigue
Fever
Headaches
Incontinence
YES
NO
Muscle weakness
Shortness of breath
Stress
Swollen glands
Weakness
PAST SURGICAL HISTORY AND HOSPITALIZATIONS:
Reason
Date
Reason
Date
PAST MEDICAL HISTORY AND OPPORTUNISTIC INFECTIONS:
(Please check appropriate response)
YES
Anemia
Anxiety
Aspergillosis
Candidiasis
Cancer
Type:
Carcinoma of cervix
Cardiomyopathy
Cryptococcosis
Cytomegalovirus
Depression
Diabetic
Diarrhea
Ear infections
Endocarditis
Epilepsy
Esophagitis
GI infections
NO
YES
Hepatitis
Type: A B C
Herpes simplex virus
Herpes Zoster
Histoplasmosis
HIV encephalopathy
HIV wasting syndrome
Kaposi’s Sarcoma
Lymphoma
Meningitis
Mucormycosis
Recurrent bacterial inf
Mycobacterial infection
Nephropathy
Nocardiosis
Other mental illness
Peripheral Neuropathy
PCP
Pneumonia
NO
YES
Pulmonary tuberculosis
Salmonella bacteremia
Sepsis
Septic arthritis
Shingles
Sinusitis
Skin infections
Strongyloidiasis
Syphilis
Thrombocytopenia
Thrush
Toxoplasmosis
Tuberculosis
Tuberculosis exposure
Urinary infections
Vaginal yeast infections
NO
SOCIAL HISTORY:
(Please check response)
MARITAL STATUS:  MARRIED SINGLE  WIDOW  DIVORCED
Sexual Orientation; [] Heterosexual [] Homosexual [] Bisexual.
Do you smoke cigarettes? [] Never [] Former Smoker [] Occasional [] Current every day smoker
If yes, how many packs per day? _________. How many years? ___________.
If no, have you ever smoked in the past? _____________. Have you quit? [] Yes [] No
Do you drink alcohol? [] Never [] Occasional [] Moderate [] Heavy.
How much? ___________________________ . Have you quit? [] Yes [] No
Caffeine Intake? [] Never [] Occasional [] Moderate [] Heavy. How much? _________________________
..
Do you chew or smoke Tobacco? [] Never [] Occasional [] Moderate [] Heavy.
How many years? _______________ . Have you quit? [] Yes [] No
Recreational Drugs? [] Never [] Former [] Occasional [] Current. Have you quit? [] Yes [] No
What type of drugs? ____________________________. How many years? ___________________ .
Animal exposure and which one? ______________________________________.
How many Children? _____________ .
How many Siblings? ______________.
FAMILY HISTORY:
Write family member in the
space provided
Bleeding disorder
Cancer (List type)
Diabetes
Epilepsy
Glaucoma
Heart disease
HIV
Hypertension
Kidney disease
Mental illness
Osteoporosis
Stroke
Thyroid disease
Maternal side
Paternal side
PLEASE PRINT CLEARLY
GENERAL
INFORMATION
WHO IS YOUR REGULAR
PHYSICIAN?
TODAY'S DATE:
Pharmacy Name;
PHYSICIAN’S TELEPHONE
(
)
Pharmacy No:
 YES
DID HE/SHE REFER YOU TO
Pharmacy Fax:
US?
IF NOT, HOW DID YOU FIND OUT ABOUT OUR PRACTICE?
PATIENTS NAME:
 NO
BIRTHDATE:
(Last)
(First)
AGE:
(Middle)
SEX:
MARITAL STATUS:  MARRIED
SOCIAL SECURITY #:
M F
 SINGLE  WIDOW  DIVORCED
RACE: (optional)
 CAUCASIAN  BLACK  HISPANIC OR LATIN ASIAN
 AMERICAN INDIAN OR ALASKAN NATIVE  AMERICAN INDIAN OR PACIFIC ISLANDER
HEIGHT: __________________________________
WEIGHT: ___________________________
ADDRESS:
(Street)
HOME PHONE: (
(Apt#/PO Box#)
)
(City)
CELL PHONE (
(State)
)
WORK PHONE: (
IF WE NEED TO REACH YOU, AT WHICH NUMBER DO YOU WANT TO BE CALLED?
ARE YOU PREGNANT?
 YES
EMPLOYER:
(Zip Code)
 HOME
 CELL
 NO
ADDRESS:
NAME OF SPOUSE (OR PARENT):
PHONE: (
SOCIAL SECURITY NUMBER OF SPOUSE (OR PARENT):
DOB:
PERSON TO CONTACT IN CASE OF EMERGENCY:
RELATIONSHIP:
)
PHONE: (
)
EMAIL ADDRESS:
WOULD YOU LIKE INFORMATION SENT TO YOU BY EMAIL?:  YES
 NO
)
 WORK
I, _____________________________________________, have received a copy of this office’s Notice of Privacy
Practices.
Patient’s Name
________________________________________________________________________
Patient’s Signature
________________________________________________________________________
Date
________________________________________________________________________________
FOR OFFICE USE ONLY
We attempted to obtain written acknowledgment of receipt of your Notice of Privacy Practices, but acknowledgment
could not be obtained because:
________
Individual refused to sign
________
Communication barriers prohibited obtaining the acknowledgment
________
An emergency situation prevented us from obtaining acknowledgment
________
Other____________________________________________________
FROM:
TO:
DATE:
PATIENT:
D.O.B.:
SOCIAL SECURITY#:
DATE(S) OF SERVICE:
MED REC#:
The above named patient is currently being treated by:
Dr. Cobian
Dr. Aklilu
Please forward to us copies of all pertinent records you have on this patient. An “Authorization to
Release Medical Information” signed by the staff is provided below. Thank you in advance for your
assistance.
Signature:
The patient has an appointment on:
Please forward to us the following components of the medical record:
Entire Medical Record
History and Physical
Consult Reports
Discharge Summary
Operative Reports
Pathology Reports
Lab Reports
Microbiology Reports
Radiology Reports
ECG Reports
Progress Notes
Physician Orders
Forward the records by:
Telephone: 954-489-2260
Facsimile: 954-489-2261
Mail
Courier
Leave in doctors mail box
Other:
Comments:
I authorize and request the above named facility to furnish to Aklilu & Cobian Infectious Diseases,
information concerning my case history, treatment, examinations, etc. I understand that this
disclosure may contain psychiatric, substance use, AIDS diagnosis and or treatment, or HIV test
results. I understand this information if faxed/mailed may be misdirected and Aklilu & Cobian
Infectious Diseases shall be held harmless. The clinical information will be regarded as CONFIDENTIAL
and will be used solely for the purpose of my treatment while I am a patient under their care.
PATIENT’S SIGNATURE:
___________________________________
SIGNATURE ON FILE-LIFETIME AUTHORIZATION FOR COMMERCIAL
INSURANCE AND MANAGED CARE MEMBERS
I authorize the release of any medical information necessary to process this claim. I authorize my doctor to act as my agent
in helping me obtain payment from my insurance companies. I authorize you to give me reasonable and proper medical care
by today's standards. I authorize payment of medical benefits directly to of Aklilu and Cobian Infectious Diseases LLC for
services rendered. I understand I am financially responsible for any balance not covered by my insurance carrier. I permit a
copy of this authorization to be used in place of my original signature. Should this become a collection problem, the
(client/debtor/patient) assumes all costs of collection, including, but not limited to court costs, interest, and legal fees.
PRINTED NAME:
____________________________________
SIGNED:
DATE:
MEDICARE/MEDICAID AUTHORIZATION
I request that payment of authorized Medicare and Medicaid benefits be made either to me or on my behalf to of Aklilu and
Cobian Infectious Diseases LLC any services furnished me by that group of physicians. I authorize any holder of medical
information about me to release to the Health Care Financing Administration and its agents any information needed to
determine these benefits or the benefits payable for related services. I understand my signature requests that payment be
made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is indicated in
item 9 of the HCFA-1500 form, or elsewhere on the other approved claim forms or electronically submitted claims, my
signature authorizes release of the information to the insurer or agency shown. In Medicare assigned cases, the physician or
supplier agrees to accept the charge determination of the Medicare and Medicaid carrier as the full charge, and the patient is
responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon
the charge determination of the Medicare and Medicaid carrier.
PRINTED NAME:
SIGNED:
DATE:
MEDIGAP BENEFICIARY SIGNATURE AUTHORIZAION
I request that payment of authorized Medigap benefits be made on my behalf to of Aklilu and Cobian Infectious
Diseases LLC for services furnished me by the physician(s) of Aklilu and Cobian Infectious Diseases LLC. I authorize
the holder of information about me to release to (Insurance Company Name)
________________________________________ any information needed to determine these benefits or the benefits
payable for related services. I understand that I am responsible for payment of any balance not paid by my insurance
company.
PRINTED NAME:
SIGNED:
DATE:
AUTHORIZATION TO RELEASE RECORDS
I authorize __________________________________________________________________________ to receive
medical records or information regarding my health at any time.
PRINTED NAME:
SIGNED:
DATE:
SECTION A: Patient Giving Consent
Patient’s Name
_____________________________________________________________________________
Address
____________________________________________________________________________________
Telephone
_________________________________ Social Security number______________________
SECTION B: To the Patient-Please read the following statements
carefully
Purpose of Consent. By signing this form, you will consent to our use and disclosure of your protected health
information to carry out treatment and payment activities.
Notice of Privacy Practices. You have the right to read our Notice of Privacy Practices before you decide whether to
sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of
the uses and disclosures we may make of your protected health information, and of other important matters about your
protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully
and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our
privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes
may apply to any of our protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by
contacting our office.
Right to Revoke. You will have right to revoke this Consent at any time by giving us written notice of your revocation
submitted to our office. Please understand that revocation of this Consent will not affect any action we took in reliance
on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if
you revoke this Consent.
SECTION C: Signature
I, ____________________________________________________, have had the full opportunity to read and consider
the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form,
I am giving my consent to your use and disclosure of my protected health information to carry out treatment and
payment activities.
I authorize the following people to receive medical records or information regarding my health at any time.
________________________________
Name
________________________________
Name
PATIENT’S SIGNATURE:
_________________________________
Relationship
_________________________________
Relationship
__________________________________ Date: _______________
Section A
Payment Guarantee:
The undersigned patient and guarantor, if any, herby to pay all Aklilu & Cobian Infectious Diseases,
LLC charges to Aklilu & Cobian Infectious Diseases, LLC in accordance with the regular rates and
terms of Aklilu & Cobian Infectious Diseases, LLC and agree to pay for any charges not covered by
any third party payer. The Medical Practice files insurance as a courtesy to the patient, but the
patient is ultimately responsible for payment of the total incurred charges. The undersigned agree
that if this account is turned over to a collection agency or attorney, that the undersigned patient and
guarantor, if any, shall be obligated to pay the outstanding balance plus all costs of collections
including reasonable fees. The undersigned agree that any overpayments collected on this account
may be applied to any delinquent account for which the undersigned patient is legally responsible.
The undersigned patient and guarantor, if any, herby agree that they are jointly and severally liable
to pay the entire balance due and that Aklilu & Cobian Infectious Diseases, LLC is relying upon the
undersigned(s) promise to pay in treating the patient.
X
Patient Signature & Date
Section B
No Show Fee:
If a patient does not show to a scheduled appointment or does not call to cancel an appointment,
after 3 times, there will be a $25.00 fee. This will apply to every appointment that was not cancelled
in advance after the first 3 no shows.
X
Patient Signature & Date
Section C
MEDICATION HISTORY AUTHORITY
Aklilu and Cobian Infectious Diseases have gone to Electronic Medical Records (EMR). In doing
so, we would need your permission in order to access your medications electronically from your
pharmacy. This will ensure that our doctors will provide the best possible care to you.
X
Patient Signature & Date