Download REGISTRATION SURGICAL SPECIALISTS, S

REGISTRATION FORM
SURGICAL CARE ASSOCIATES
71 West 156th Street, Suite 309
Harvey, Illinois 60426
Telephone: (708) 331-1122
Fax: (708) 331-5987
THIS FORM MUST BE COMPLETELY FILLED OUT BEFORE BEING SEEN BY THE PHYSICIAN
Date___________________ Home Phone (____) _____________________ Cell Phone (____) ____________________
PATIENT INFORMATION
Last Name______________________________________ First Name___________________________ M.I._________
Address______________________________________ City________________________ State________ Zip________
Male____ Female____ Birth date ____________ Race _______________Language Spoken _____________________
Email _________________________________
Last 4 digits Social Security XXX-XX-_______________
Single________ Married_________ Divorced________ Widowed________ Minor_________
Employer________________________________________________ Employer Phone__________________________
Pharmacy ____________________Address _________________ City __________________ Phone _______________
Are you a Dialysis Patient ____yes
____no
If yes, where do you dialyze?___________________________
In case of an emergency who should we contact?______________________________ Phone (___) ________________
Name of primary care physician _______________________________________ Phone (____) ___________________
Name of referring physician ___________________________________________ Phone (____)___________________
SURGICAL CARE ASSOCIATES
Consent to the Use and Disclosure of Health Information for Treatment, Payment, or
Healthcare Operations
I, __________________________________________understand that as a part of my healthcare, this practice originates
and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment,
and plans for future care or treatment. I understand that this information serves as:
-
A basis for planning my care and treatment
A means of communication among the many health professionals who contribute to my care
A source of information for applying my diagnosis and surgical information to my bill
A means by which a third party payer can verify that services billed were actually provided
A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals
I understand that I have the right to review the Notice of Privacy Practices which provides a more complete description
of personal health information uses and disclosures. I understand that a copy of this notice will be provided upon my
request. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a
revised copy by requesting one from Surgical Care Associates or visiting our website and
www.surgicalcareassociates.com. I understand that I have the right to request restrictions as to how my health
information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization
is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the
extent that the organization has already taken action in reliance thereon.
I authorize Surgical Care Associates to electronically download prescription and insurance eligibility information.
I fully understand and accept the terms of this consent.
Signature: ________________________________________ Date: __________2016
I wish to have the following restrictions to the use or disclosure of my healthcare info:
I will allow Surgical Care Associates to leave a detailed voice mail message. NO_______ YES_______
THE FOLLOWING INDIVIDUAL(S) ARE ALLOWED BOTH VERBAL AND WRITTEN COMMUNICATION REGARDING MY PERSONAL
HEALTH/BILLING INFORMATION: ____________________________________________________________________________________ __
Acknowledgement Form for
Notice of Privacy Practices
By signing this form, you acknowledge that you have received the Notice of Privacy Practices for Surgical Care Associates
(“SCA”) which describes SCA’s use and disclosure of your individually identifiable health information and your rights with respect to
this information.
If you refuse to sign this form but receive health care services from SCA, you have implicitly consented to SCA’s use
and disclosure of your individually identifiable health information as described in our Notice of Privacy Practices.
Patient’s Signature: _______________________________________
Patient’s Name (printed): __________________________________ Date:
_____2016
If patient is unable / unwilling to acknowledge receipt or is a minor, complete the following:
Patient is:
_________ a minor
_________ unable
_________ unwilling
Signature of Personal Representative (if applicable): ______________________________
Personal Representative’s Name (Print): ___________________________________
Relationship to Patient: _______________________________________________________
SURGICAL CARE ASSOCIATES
R. Deshmukh, M.D. C. Johnson, M.D. G. Peplinski, M.D.
Comprehensive Patient History Form
Patient Name: _________________________________
DOB: _________________ Age: ________ Today’s Date: _____________
Primary Care Physician: _____________________________ Referring Physician Phone: ______________________________________
Describe your main problem ____________________________________________________________________________________
Are you currently being treated for :
Diabetes………………. yes
High blood pressure……. yes
Cancer………………… yes
Stroke…………………. yes
Heart trouble………….. yes
Arthritis/gout…………. yes
Convulsions…………… yes
Bleeding tendency…….. yes
Chronic Renal Failure..... yes
Asthma………………… yes
Thyroid disease………… yes
Allergies to Medication
What Medications are you taking?
❏ I do not take any medication
1.___________________
2.___________________
3.___________________
4.___________________
5.___________________
❏ No
known
Medication Allergies
1)_____________________________
2)_____________________________
3)_____________________________
4)_____________________________
5)_____________________________
6)_____________________________
7)_____________________________
❏ Denies any medical
problems………..yes
8)_____________________________
9)_____________________________
10)____________________________
List previous Surgeries
When?
__________________________________
____________________
__________________________________
____________________
__________________________________
____________________
__________________________________
____________________
❏ No
11)_______________________
Surgical History
__________________________________________
Patient Social History
________________________
Use of____________________
tobacco:
❏ Never
____________________
❏ Previously quit
❏ Currently smoke:
___ packs per day
___ occasionally
___socially
Family Medical History ❏ Noncontributory
Age
Diseases
If Deceased, Cause of Death
Father
_____
________________________________________________________ ____________________________
Mother
_____
________________________________________________________ ____________________________
Siblings
_____
________________________________________________________ ____________________________
_____
________________________________________________________ ____________________________
PLEASE ANSWER ALL QUESTIONS
Have you traveled to West Africa? (Guinea,
Libera, Sierra, Leone, Sengal, Nigeria)
Yes
or
No
If yes, have you experienced any of these symptoms
(circle all that apply)






Fever
Headache
Weakness
Diarrhea
Rash
Bleeding
_______________________________________________________________
Have you had any of the following during the past three months?
If you have had any of these, circle yes
CONSTITUTIONAL
Good general health lately……………………..
Recent fever………….………………………….
Recent weight gain……………………………...
Fatigue…………………………………………
Headaches……………………………………...
Recent weight loss……………………….……
Frequent illness………………………………..
CARDIOVASCULAR
Chest pain/pressure…………………………..
Sudden heart beat changes……………………..
Swelling of feet, ankles or hands………………
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
RESPIRATORY
Frequent coughing……………………………...
Spitting up blood……………………………….
Shortness of breath……………………………..
Yes
Yes
Yes
GASTROINTESTINAL
Loss of appetite…………………………………
Change in bowel movements…………………..
Nausea or vomiting…………………………….
Frequent diarrhea………………………………
Blood in stool…………………………………..
Abdominal pain…………………………………
Yes
Yes
Yes
Yes
Yes
Yes
Date: ______________________
Patient Signature: ___________________________________
GENITOURINARY/NEPHROLOGY
Urinary urgency………………………………
Burning or painful urination……………………
Blood in urine…………………………………..
Change of force of strain when urinating………
Urinary incontinence……………………….
Kidney stones…………………………………..
Yes
Yes
Yes
Yes
Yes
Yes
MUSCULOSKELETAL
Joint pain, stiffness or swelling………………..
Weakness of muscles or joints…………………
Muscle pain or cramps…………………………
Cold extremities………………………………...
Difficulty in walking……………………………
Yes
Yes
Yes
Yes
Yes
SKIN
Rash, dry or itching skin ……………………….
Varicose veins…………………………………..
Yes
Yes
BREAST
Breast pain………………………………………
Breast lump……………………………………..
Breast discharge…………………………………
Yes
Yes
Yes
NEUROLOGICAL
Dizziness………………………………...
Numbness or tingling sensations………………..
Tremors…………………………………………
Paralysis………………………………………...
Head injury………………………………………
Yes
Yes
Yes
Yes
Yes
ENDOCRINE
Glandular or hormone problem…………………
Excessive thirst or urination……………………
Yes
Yes
HEMATOLOGIC/LYMPHATIC
Slow to heal after cuts………………………….
Easily bruise or bleed…………………………..
Anemia………………………………………….
Phlebitis…………………………………………
Past transfusion…………………………………
Lymph node enlargement/mass…………………
Yes
Yes
Yes
Yes
Yes
Yes
SURGICAL CARE ASSOCIATES
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependents, have insurance coverage with _____________________________ and assign
(Insurance company name)
Directly to Surgical Care Associates all insurance benefits, if any, otherwise payable to me for services rendered. I
understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my
signature on all insurance submissions.
The above named practice may use my health care information and may disclose such information to the above named
Insurance Company(ies) and their agents for the purpose of obtaining payment of services and determining insurance
benefits or the benefits payable for related services.
________________________________________________________________
Signature of Patient, Parent, Guardian or Representative
______________________2016
Date
________________________________________________________________
Please print name of Patient, Parent, Guardian or Representative
_________________________
Relationship to Patient
OFFICE POLICIES AND PROCEDURES
Insurance
All Patients are required to check with his/her own insurance company to verify our doctor is listed
in your plan and what is covered by your plan. Patients are required to present a current insurance
card and referral, if needed, otherwise appointment may be rescheduled.
Each insurance plan is different and we have no way of knowing what each individual plan covers.
In order to prevent misunderstandings about medical insurance, we wish to point out the following
-Patients are personally responsible for payment of any and all bills, deductibles and
balances.
-Patients should expect to keep their accounts current while waiting for their insurance
company to make payment.
Monthly Billing Statements
Every month our office sends out a monthly billing statement to every patient. The balance due is the remainder owed
after your insurance has paid. It is your responsibility to pay your monthly statement each month even if you and your
insurance company are disputing coverage.
If you have negotiated a payment plan with us you are responsible for making timely and consistent monthly payments.
We offer payment plans as a courtesy to our patients in time of need. If you fail to make your scheduled monthly
payment and do not contact our office before your scheduled due date, your account will be sent to collections for nonpayment.
Collections
If your account balance is unpaid and overdue after three or more monthly statements and you have not responded to any
of our attempts to contact you, your account will be referred to a collection agency. Once your account is in collections
you may be dismissed from our practice and any further communication concerning your account will be between you and
the collection agency. Again, please note that we will only proceed to these measures if you do not respond to our
attempts to communicate with you and set up a payment plan.
You agree to reimburse us the fees of any collection agency, which may be based on a
percentage at a maximum of 27% of the debt, and all costs, and expenses, including
reasonable attorneys’ fees, we incur in such collection efforts.
Late For Appointments
Please try to make every effort to notify our office if you will be arriving late. If you will be more
than 20 minutes late we may need to reschedule your appointment or we may ask that you wait until
the next open spot on the schedule while we continue to see the patients who have been arriving on
time.
Missed Appointment
Occasionally patients are faced with emergencies or unavoidable circumstances that may coincide
with a previously arranged appointment. We would appreciate a call at least 24 hours in advance to
cancel and reschedule appointment. You may be dismissed from the practice after 3 missed
appointments.
Patient Signature__________________________________________ Date _______________2016
Patient Name (PRINT)_____________________________________