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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