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HOWARD J. LANG, D.O., F.A.A.E.M.
DEREK H. LANG, D.O.
789 Lonesome Dove Trail
Hurst, Texas, 76054
Phone: 817-577-0480 Fax: 817-581-0167
WELCOME TO OUR PRACTICE
WE APPRECIATE THAT YOU HAVE SELECTED OUR PRACTICE TO SERVE YOUR MEDICIAL
NEEDS. TO HELP US PROVIDE YOU THE BEST MEDICAL CARE, WE ASK THAT YOU PLEASE
READ THE FOLLOWING SO YOU WILL BECOME MORE FAMILIAR WITH US.
APPOINTMENTS MAY BE SCHEDULED FROM 10:15 A.M. TO 4:15 P.M., MONDAY THROUGH
THURSDAY. THE OFFICE IS CLOSED FOR LUNCH BETWEEN 1:00 P.M. – 2:15 P.M. IF FOR
ANY REASON YOU ARE UNABLE TO KEEP YOUR APPOINTMENT, PLEASE CONTACT US
WITHIN 24 HOURS TO CANCEL OR RESCHEDULE.
DRS. HOWARD AND DEREK LANG ARE OUT OF THE OFFICE ON FRIDAYS, BUT THE OFFICE
IS OPEN FROM 8:00 A.M. – 12:00 NOON FOR PATIENTS TO PICK UP SUPPLEMENTS,
ALLERGY VIALS OR OTHER NON-PHYSICIAN SERVICES. THE NURSE IS UNABLE TO
“TREAT” ANY PATIENT DURING THIS TIME SINCE A PHYSICIAN IS NOT ON DUTY. IF YOU
NEED EMERGENT CARE, YOU WOULD NEED TO GO TO THE EMERGENCY ROOM OR AN
EMERGENCY CLINIC.
PLEASE FEEL FREE TO CALL OUR OFFICE IF YOU HAVE ANY QUESTIONS REGARDING
YOUR CONDITION, MEDICATION, OR TREATMENT. TRAINED MEDICAL PERSONNEL WILL
ANSWER YOUR QUESTIONS.
IF YOU NEED A REFILL ON YOUR MEDICATION(S), PLEASE CALL YOUR PHARMACY. IF
YOU HAVE NO MORE REFILLS LEFT, THE PHARMACY
WILL THEN FAX A REFILL REQUEST TO OUR OFFICE AT WHICH TIME THE NURSE WILL
CONCUR WITH THE DOCTOR. YOU WILL EITHER GET AN AUTHORIZED REFILL FAXED
BACK TO THE PHARMACY OR THE NURSE WILL CALL YOU IF FURTHER APPOINTMENTS
OR COMMUNICATION IS NEEDED.
AFTER OFFICE HOURS, EMERGENCIES OR COMPLICATIONS ARE HANDLED BY OUR
ANSWERING SERVICE. THE ANSWERING SERVICE CANNOT TAKE REFILL REQUESTS OR
ADVISE IN ANY MEDICAL TREATMENT. IF YOU CALL AFTER HOURS, OUR RECORDED
MESSAGE WILL PROMPT YOU AS TO HOW TO SPEAK WITH OUR ANSWERING SERVICE.
PLEASE TRY AND MAKE ALL NON-EMERGENCY CALLS DURING REGULAR OFFICE
HOURS.
IF YOU HAVE BEEN REFERRED TO US BY ANOTHER PHYSICIAN, PLEASE LET US KNOW
SO WE MAY REPORT TO HIM OR HER PROMPTLY.
**********VERY IMPORTANT**********
BECAUSE MANY OF OUR PATIENTS HAVE ALLERGIES, WE REQUEST THAT YOU
REFRAIN FROM WEARING PERFUME, AFTERSHAVE OR ANY TYPE OF FRAGRANCE
WHEN YOU VISIT THE OFFICE. ALSO, WE ARE A NON-SMOKING FACILITY.
________________________________________________________________________
WE ARE NOT PROVIDERS WITH ANY INSURANCE GROUP
PAYMENT FOR PROFESSIONAL SERVICES IS DUE AT THE TIME TREATMENT IS
RENDERED. FOR YOUR CONVENIENCE, WE ACCEPT CASH, CHECKS, VISA,
MASTERCARD AND DISCOVER. WE DO NOT ACCEPT AMERICAN
EXPRESS.
MANY OF OUR PATIENTS HAVE HEALTH INSURANCE COVERAGE. YOU WILL BE
GIVEN A RECEIPT AT YOUR VISITS THAT WILL ENABLE YOU TO FILE YOUR CLAIM
WITH EASE. PLEASE REMEMBER THAT YOUR INSURANCE POLICY IS AN
AGREEMENT BETWEEN YOU AND YOUR INSURANCE COMPANY. YOU ARE
RESPONSIBLE FOR PAYMENT OF ALL CHARGES AT THE TIME OF SERVICE.
WE HOPE THE ABOVE INFORMATION IS HELPFUL TO YOU. PLEASE DON’T HESITATE TO
ASK ANY OF OUR STAFF FURTHER QUESTIONS THAT YOU MAY HAVE.
Thank you,
Dr. Howard J. Lang, D.O., F.A.A.E.M.
Dr. Derek H. Lang, D.O.
I understand that my signature represents that I have read and understand the
above policies. I agree to make payment in full at the time of my office visit(s).
___________________________________
SIGNATURE
____________________________
DATE
INSTRUCTIONS FOR LEAVING MESSAGES AND/OR DISCUSSING YOUR
MEDICAL CONDITION WITH OTHERS
SPEAK ONLY TO ME
___YES ___NO _____INITIALS
OK TO SPEAK TO MY SPOUSE ___YES ___NO _____INITIALS
OK TO SPEAK TO MY PARENTS
___YES ___NO _____INITIALS
OK TO LEAVE MESSAGE ON
ANSERING MACHINE ___YES ___NO _____INITIALS
OK TO LEAVE MESSAGE ON
VOICEMAIL ___YES ___NO _____INITIALS
OTHER (specify) _______________
(Such as grandparent, other relative)
___YES ___NO _____INITIALS
______________________
_________________________
DATE
SIGNATURE
_____________________________________________________________
PLEASE LIST THE NAMES OF FAMILY OR FRIENDS THAT MAY PICK UP
YOUR ALLERGY VIALS, VITAMINS OR
PRESCRIPTIONS:_______________________________________________________
__________________________________________________
Your insurance company may request additional information so that your claim may be
processed. We will need your signature to authorize us to send any additional information
they may need to process your claim. If you choose not to sign, your claim may not be
able to be processed efficiently, therefore delaying or possibly denying any
reimbursement due to you.
_________________________________
Signature
____________________
Date
PATIENT INFORMATION
How did you hear about our practice?_______________________Today's Date___________
Patient Name:_________________________________Age:________Date of Birth:__________
Street Address:________________________________City/State:______________Zip:________
Phone:(H)_______________________(W)_____________________Cell_____________________
Marital Status: M
S D W
Social Security Number:_____________________
If Patient is a minor, responsible party's name:_______________________________________
Relationship to
patient:_______________Address:_____________________________________
Phone:__________
Employer's Name & Address:_______________________________________________________
____________________________________Position:___________________
Signature of party responsible for payment:__________________________________________
Medicare Eligible Patients
I,___________________________________, understand that Dr. Howard J. Lang &
Dr. Derek H. Lang has "opted out" of Medicare, effective November 1, 2004. I also understand
that I will be responsible for payment of all charges incurred after the above date, including any
laboratory work-up (blood studies). I further understand that these charges will not be sent to
Medicare (no reimbursement) nor to my secondary insurance company (no reimubursement
Since Medicare
does not pay).
I agree to be responsible for all expenses incurred.
Patient Name:_______________________________
Medicare #:_________________________________
Date:_______________________________________
PATIENT: ________________________________________
DATE: __________________
1.) PROBLEMS that bring you to see the doctor.
2.) PAST MEDICAL HISTORY: (all disease diagnoses)
3.) ALLERGIES: (to drugs, antibiotics, pollens, and/or chemicals… describe reaction)
4.) MEDICATIONS YOU ARE NOW TAKING:
5.) SURGERIES: (year/month if known…
operation…
6.) HOSPITALIZATIONS: (year/month if known…
7.) INJURIES: (year/month if known…
physician if known)
operation…
operation…
physician if known)
how injury occurred)
8.) CHILDHOOD DISEASES AND VACCINATIONS: (copy of vaccine record OK)
9.) LIST FOODS THAT YOU REACTED TO AS A CHILD OR NOW:
10.) OB-GYN HISTORY:
a.) age at onset of menstruation:
b.) age that menstruation stopped:
c.) first day of last menstrual period:
d.) date of last pap smear
e.) number of pregnancies
f.) number of term deliveries
g.) number of preterm deliveries
h.) number of miscarriages
i.) number of abortions
j.) number of living children
k.) ages of children
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
11.) Family History
Heart Disease
Heart Attack
Diabetes
Hyperthyroidism
Hypothyroidism
High Blood Pressure
Stroke
Epilepsy
Cancer
Tuberculosis
Emphysema
Asthma
Allergies
Liver Disease
Alcoholism
Stomach Ulcer
Duodenal Ulcer
Kidney Disease
Glaucoma
Sickle Cell Anemia
Other Anemia
Mental Illness
Suicide
Birth Defects
Genetic Disease
Other Serious Disease
Father
Mother
Other Immediate Family
Elaboration?
12.) SOCIAL HISTORY
a.) Occupation
i.) Past occupations
b.) Married or single (circle one)
i.) Number of times married ___________
c.) Smoking history
(average number of packs per day… number of years used)
d.) Alcohol history
i.) Beer
ii.) Wine
iii.) Liquor
(type, frequency of use, number of years used)
How often? ___/wk ___/mo ___/yr
How many years? ____
How often? ___/wk ___/mo ___/yr
How many years? ____
How often? ___/wk ___/mo ___/yr
How many years? ____
e.) Illicit or intravenous drug use (type, frequency of use, number of years)
f.) Other pertinent social history
PATIENT: ________________________________________ DATE: __________________
____________________________REVIEW OF SYMPTOMS________________________
1.) HEAD and NECK
___Frequent or persistent headaches
___Neck pains
___Neck lumps or swelling
2.) EYES
___Wear glasses
___Blurry vision
___Double vision / seeing double
___Seeing halos
___Eye pain or itching
___Watering eyes
___Eye trouble
3.) EARS
___Hearing difficulties
___Earaches
___Drainage from ears
___Ringing or buzzing in ears
___Motion sickness
4.) MOUTH
___Dental problems
___Swelling on gums/jaws
___Sore tongue
___Taste changes
5.) NOSE and THROAT
___Congested nose
___Running nose
___Sneezing spells
___Head colds
___Nosebleeds
___Sore throat
___Enlarged tonsils
___Persistent hoarseness
6.) RESPIRATORY
___Wheezes or gasps
___Coughing spells
___Coughing up phlegm
___Coughing up blood
___Chest colds / bronchitis
___Excessive sweating
___Rib pain with breathing
7.) CARDIOVASCULAR
___High blood pressure
___Low blood pressure
___Racing heart or irregular heartbeat
___Chest pain
___Shortness of breath
___Dizzy spells
___Leg cramps
___Hot flashes
___Heart murmur
___History of rheumatic fever
8. DIGESTIVE
___Poor appetite
___Heartburn or indigestion
___Bloated stomach
___Belching
___Abdominal pain
___Nausea
___Vomiting
___Vomiting blood
___Difficulty swallowing
___Constipation
___Loose stools
___Black or tar-like stools
___Grey stools
___Pain in rectum
___Rectal bleeding
___Gallbladder problems
___Hemorrhoids
9.) URINARY
___Frequency at night
___Frequency during the day
___Wet pants or bed
___Burning on urination
___Brown, black or bloody urine
___Difficulty starting urine
___Urgency
10.) MALE GENITAL
___Weak urine stream
___Prostrate problem
___Discharge or burning
___Lumps on testicles
___Painful testicles
11.) FEMALE GENITAL / BREAST
___Menstrual trouble
___Breakthrough bleeding
___Heaving bleeding
___Premenstrual bleeding / spotting
___Birth control pill
___Lumps in breasts
___Vaginal discharge
___Normal or abnormal pap smear
___Breast lump(s)
___Discharge from nipple
PATIENT: ________________________________________ DATE: __________________
____________________________REVIEW OF SYMPTOMS________________________
___Other breast problem
___Lonely or depressed
12.) MUSCULOSKELETAL
___Cries often
___Aching joints or muscles
___Hopeless outlook
___Swollen joints
___Difficulty relaxing
___Back or shoulder pain
___Worry a lot
___Painful feet
___Frightening dreams or thoughts
___Handicapped
___Shy or sensitive
___Lump/swelling on muscle or bone
___Dislikes criticism
13.) SKIN
___Lose temper
___Skin problems
___Annoyed by little things
___Itching or burning skin
___Work or family problems
___Bleed easily
___Sexual difficulties
___Bruise easily
___Considered suicide
14.) NEUROLOGICAL
___Attempted suicide
___Fainting spells
___Desired psychiatric help
___Dizziness
17.) GENERAL
___Numbness
___Weight gain
___Convulsions
___Weight loss
___Change in handwriting
___Loss of interest in eating
___Trembling
___Armpits or groin swelling
___Difficulty with balance
___Fatigue / tiredness
___Weakness in arm, leg, back or neck
___Generalized weakness
___Speech difficulty
___Bites nails
15.) ENDOCRINE
___Difficulty falling asleep
___Hungry all the time
___Difficulty staying asleep
___Thirsty all the time
___Can’t go back to sleep after awakening
___Intolerant to cold
___Lack of exercise (<20 mins aerobic / day)
___Intolerant to heat
___Watch a lot of TV (>1 hour / day)
___Thyroid trouble
___Spend much time on computer (>1 hour / day)
___Unusually tired or sluggish
___Feel better when on vacation (out of town)
___Unusually jumpy or nervous
___Feel worse when on vacation (out of town)
16.) PSYCHOLOGICAL
___Feel same when on vacation (out of town)
___Nervous with strangers
___Feel better when I come home (f/ out of town)
___Difficulty making decisions
___Feel worse when I come home (f/ out of town)
___Lack of concentration or memory
___Feel same when I come home (f/ out of town)
HIPAA Notice of Privacy Practices
________________________________________________________________________________________________
HOWARD J. LANG, D.O.
789 Lonesome Dove Trail
Hurst, Texas, 76054
PHONE: (817) 577-0480
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment,
payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to
access and control your protected health information. "Protected health information" is information about you, including demographic
information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health
care services.
1. Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are
involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the
operation of the physician's practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related
services. This includes the coordination or management of your health care with a third party. For example, we would disclose your
protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health
information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to
diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example,
obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain
approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of
your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training
of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected
health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk
where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your
physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of
your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include:
as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight:
Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and
Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation:
Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the
Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.
Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object
unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an
action in reliance on the use or disclosure indicated in the authorization.
Your Rights
Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the
following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative
action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of vour protected health information. This means you may ask us not to use or disclose any part
of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of
your protected health information not be disclosed to family members or friends who may be involved in your care or for notification
purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want
the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use
and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use
another Healthcare Professional.
You have the right to request to receive confidential communications from us bv alternative means or at an alternative location. You have
the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e.
electronically.
You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you
have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy
of any such rebuttal.
You have the right to receive an accounting! of certain disclosures we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or
withdraw as provided in this notice.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.
You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a
complaint.
This notice was published and becomes effective on/or before April 14, 2003.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy
practices with respect to protected health information. If you have any objections to this form, please ask to speak with our
HIP AA Compliance Officer in person or by phone at our Main Phone Number.
Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:
Print Name:___________________________Signature:____________________________ Date:_________________