GUADALUPE ENT, P.A. JENNIFER G. HENNESSEE, M.D. MAANSI DOSHI, D.O. LISA M. WRIGHT, PA

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1 GUADALUPE ENT, P.A. JENNIFER G. HENNESSEE, M.D. MAANSI DOSHI, D.O. LISA M. WRIGHT, PA Patient Profile Last Name First Name Middle Name of Birth Gender Social Security Number Marital Status Race Ethnic Group Preferred Language Address City State Zip Code Preferred Number (Home Cell Work) Secondary Number (Home Cell Work) Alternate Number (Home Cell Work) Guadalupe ENT, PA provides the option for you to receive your account billing statements / invoices by . I understand that by agreeing to receive billing statements / invoices, by , it is my responsibility to maintain a current address on file. I do understand that by agreeing to receive electronic mail, I will not receive any statements or invoices by US mail. Do you consent to receiving billing statements from Guadalupe ENT, PA by ? Yes [ ] No [ ] Preferred Address to send billing statements / invoices: Insurance Information Primary Insurance Company Insurance Policy Number Insurance Group Number Policy Holder Relationship to patient of Birth Social Security Number Policy Holder s Address City State Zip Code Policy Holder s Employer Secondary Insurance Company Insurance Policy Number Insurance Group Number Policy Holder Relationship to patient of Birth Social Security Number (PLEASE TURN TO BACK OF PAGE)

2 Demographic Sheet (page 2 of 2) Primary Emergency Contact: (PARENT S PLEASE LIST YOURSELVES AS AN EMERGENCY CONTACT) Name: Address: City: State: Zip: Primary Contact Number: Secondary Number: Relationship to Patient: ACKNOWLEDGMENT OF RECEIPT OF THE NOTICE OF PRIVACY PRACTICES I acknowledge that Guadalupe ENT, PA has provided me with a written copy of the Notice of Privacy Practices. I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices, and ask questions. May we release health information about you to family member(s) or other individuals / care giver(s)? [ ] yes or [ ] no If you answered yes, please list the names of each individual below. Patient s Signature Personal Representative Signature (if applicable) Relationship to patient PLEASE NOTE: It is the responsibility of the patient, or legal guardian to notify our office if any of the above contact information changes.

3 1.) Permission for Treatment: I hereby authorize the physician and /or assistants for the care of the patient named on this record to administer treatment as may be deemed necessary including examinations or treatments that may be ordered to be performed by clinical personnel. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me to the result of examinations or treatments to be performed. 2.) Permissions for Release of Medical Information: I understand and agree that any of the above information may be used, if necessary, for purposes of the communication for appointment changes, accounts receivable, emergencies, etc. Information from any medical records may be released, if necessary, for insurance purposes. 3.) Assignment of Benefits: I hereby authorize my insurance company(s) to make payment(s) as stipulated in my policy for any services furnished and that such payment(s) be paid directly to the provider of the services. 4.) Payment for Services Rendered: I also understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services tendered and I agree to pay upon demand or as agreed for the related changes of remaining charges following my insurance payment(s). Signature MISSED APPOINTMENT POLICY Failure to give 24 hour notice of cancellation of an appointment or no-showing an appointment will result in a charge of $25 on the patient s account. This charge cannot be billed to your insurance company. Failure to pay a no show fee will be treated according to our policy on unpaid balances, with the exception of collection accounts. Medical care will not be withheld for medical emergency. Not showing up to (3) appointments can result in the patient being discharged from the practice, at the physician s discretion. Emergency missed appointments will be taken into consideration. [ ] YES, I understand and acknowledge the Missed Appointment Policy. Signature Physician Assistant Consent for Treatment This facility has on staff a physician assistant (Lisa M. Wright, PA-C) to assist in the delivery of medical (otolaryngology) care. A physician assistant is not a doctor. A physician assistant is a graduate of a certified training program and is licensed by the state board. Under the supervision of a physician, a physician assistant can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. Supervision does not require the constant physical presence of a supervising physician, but rather overseeing the activities of and accepting responsibility for the medical services provided. I have read the above and DO consent to the services of a physician assistant. I have read the above and DO NOT consent to the services of a physician assistant. Signature: : (PLEASE TURN TO BACK OF PAGE)

4 Guadalupe Ear, Nose, and Throat, P.A. Name: Age: : Confidential Record: Information contained here will not be released except when you have authorized our office to do so. Referred by Dr. Primary Care Doctor CURRENT PROBLEMS: Please briefly state the problems that have you in to the doctor s office: ALLERGIES: (list all medication and food allergies) PREFERRED PHARMACY: Name: City: MEDICATIONS: List all medication with the dosages that you are currently taking. Include all over the counter medications, vitamins, and herbal supplements in addition to your prescription medications. Drug Name: Dosage: Qty Taken: How often taken: PLEASE PROVIDE A MEDICATION LIST IF ADDITIONAL SPACE IS NEEDED. PAST MEDICAL HISTORY MEDICAL: Have you in the past, or do your currently have the following? Asthma [ ] No [ ] Yes Year? Kidney Disease [ ] No [ ] Yes Year? Emphysema / COPD [ ] No [ ] Yes Year? GERD / Reflux [ ] No [ ] Yes Year? Heart Problems [ ] No [ ] Yes Year? Colon Disease [ ] No [ ] Yes Year? High Blood Pressure [ ] No [ ] Yes Year? Liver /Hepatitis / Cirrosis [ ] No [ ] Yes Year? Stroke / TIA [ ] No [ ] Yes Year? Cancer (what type) Year? Seizures [ ] No [ ] Yes Year? Autoimmune Disease [ ] No [ ] Yes Year? Diabetes 1 or 2 [ ] No [ ] Yes Year? ADHD [ ] No [ ] Yes Year? Thyroid Problems [ ] No [ ] Yes Year? Misc Disease not listed FOR HEART PROBLEMS, THYROID PROBLEMS, KIDNEY DISEASE, PLEASE SPECIFY TYPE OF CONDITION: (PLEASE TURN TO BACK OF PAGE)

5 SURGICAL: Have you had an operation on any of the following? Head (SPECIFY) [ ] No [ ] Yes What Surgery? Year? Neck (SPECIFY) Tonsils / Adenoids / Both Sinuses (SPECIFY) Nose (SPECIFY) Ear(s) Heart / Pacemaker Lungs / Chest Abdomen / Stomach Gall Bladder Colon Appendix Hysterectomy C-Section # Hernia (SPECIFY) Hemorrhoids Cataracts [ ] No [ ] Yes Rt / Left / Both Year? Bones / Joint Repair Other Surgeries not listed FAMILIY MEDICAL HISTORY: Who in your family has the following? Mat = Maternal / Pat = Paternal / GM = Grandmother / GF = Grandfather Father Mother Sister Brother Mat GM Mat GF Pat GM Pat GF Hearing Problems [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Asthma [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Lung Disease / COPD / Emphysema [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Heart Disease [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] High Blood Pressure [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Stroke / TIA [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Kidney Disease [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Seizures [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] GERD / Reflux [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Liver Disease / Cirrhosis / Hepatitis [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Diabetes (Type 1 or 2) [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Cancer (type) [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Autoimmune Disorders [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Other Medical Condition: [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] ADULT SOCIAL HISTORY: (This should be the information of the patient) ADULT s ONLY Marital Status (circle): Married Single Widowed Divorced Seperated Children: Biological #: Step Children #: Adopted #: Foster #: Patient: Employed Unemployed Retired Disabled Full-time Student Occupation: Job Title: Business Name: Smoking (past or present): How many packs per day? For how long? Quit : Alcohol (past or present): Beer Wine Hard Liquor Quantity? How frequent? MINOR / CHILD s SOCIAL HISTORY: (This should be the information of the patient) Minors (under 18 years old) Day-care Grade: Name of School: Members of the Household: (please circle) Mother Father Brother(s) Sister(s) Other(s) Maternal / Paternal Grandmother Maternal / Paternal Grandfather

6 Patient s Name: : ADVANCE PROCEDURE BENEFICIARY NOTICE NOTE: YOU NEED TO BE AWARE OF YOUR HEALTH PLAN LIMITATIONS. We expect that your insurance may NOT pay for certain items or services due to your health plan limitations. Insurance companies only pay for covered items and services when their rules are met. A few procedures done in this office for diagnostic purposes are not paid for by insurance under your co-pay or office visit charge. The procedures are considered SURGICAL based on the AMA s (American Medical Association) classification. Many times these services are paid at a % only after your deductible has been met. The fact that your insurance may NOT pay for a particular item or service does not mean that you should not receive it. There is probably a good reason the service is being recommended. Many such procedures done in this office involve scopes needed to view areas of the ear, nose and throat. Scope procedures allow the physician to diagnosis problems, rule out masses / obstruction, and treat the patient accordingly. The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself. * Not knowing what may be ordered for each visit / patient prior to your appointment we are unable to call your insurance to verify your particular benefits in advance. * Scopes can range from $100 to $400 in price. PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. SIGN & DATE BELOW. [ ] YES. I want to receive these items or services. I understand that my insurance may not pay for certain items or services I receive in this office. Please submit a claim to my insurance company. I understand that you may bill me for items or services over and beyond my co-pay. I agree to be personally and fully responsible for payment. Payments are acceptable. [ ] NO. I have decided not to receive these items or services. I will not receive these items or services. I understand my decision is against medical advice and will make diagnosing and treatment of my problem difficult and possibly unsuccessful. Signature of patient or person acting on patient s behalf NOTE: Your health information will be kept confidential. Any information that we collect about you will be kept confidential in our office. Your health information may be shared with your insurance company if a claim is submitted. APBNotice.doc / BBL / 10-06

EYECARE REGISTRATION AND HISTORY

EYECARE REGISTRATION AND HISTORY PATIENT INFORMATION INSURANCE Date Who is responsible for this account? Patient Relationship to Patient Address Insurance Co. Group # City State Zip Is patient covered