PATIENT DEMOGRAPHICS



PATIENT DEMOGRAPHICS

Name (First, Middle, Last):

Date of Birth:

Sex:

Social Security Number:

Address:

Home Phone:

Cell Phone:

Email Address:

Marital Status: ___ Married ___ Single ___ Widowed ___ Divorced

Race: ___ American Indian or Alaska Native ___ Caucasian ___ Asian

___ Hawaiian or Other Pacific Islander ___ African American

Ethnicity: ___ Hispanic or Latino ___ Non-Hispanic or Latino

Preferred Language: ___ English ___Spanish ___ Other: ________________

Employer’s Name:

Employer’s Address:

PCP’s Name:

PCP’S Phone number & Address:

INSURANCE INFORMATION

|Primary Insurance | |Secondary Insurance | |

|Subscriber Name | |Subscriber Name | |

|Relationship to Patient | |Relationship to Patient | |

|Subscriber DOB | |Subscriber DOB | |

|Subscriber Sex | |Subscriber Sex | |

|Subscriber Number | |Subscriber Number | |

|Group Number | |Group Number | |

Person Responsible for Payment:

Guarantor’s Date of Birth:

Guarantor’s Social Security #

Emergency Contact Name:

Relationship to Patient:

Emergency Phone Number:

Pharmacy Name & Location:

Pharmacy Phone Number:

CONSENT AND VERIFICATION

I hereby certify that all of the information listed above is correct and up to date. ___ (initial here)

I hereby authorize the release of my medical data to other organizations in order to adjudicate the claim. ___ (initial here)

I hereby grant permission for the facility to access and view my prescription history from external sources. ___ (initial here)

FILL IN THE BUBBLES FOR ALL PAST AND CURRENT- ALL INFORMATION IS CONFIDENTIAL

Diabetes O Yes O No

High Blood Pressure O Yes O No

High Cholesterol/Lipids O Yes O No

Heart Attack O Yes O No

Stroke O Yes O No

Cancer O Yes O No If yes, what kind?________________

Arthritis O Yes O No

Thyroid Problem O Yes O No If yes, what kind?________________

Stomach/Intestinal Problems O Yes O No If yes, what kind?________________

Liver Problem O Yes O No If yes, what kind?________________

Kidney Problems O Yes O No If yes, what kind?________________

Prostate Problems O Yes O No If yes, what kind?________________

Allergies O Yes O No Serious

Injury/ Head Injury O Yes O No If yes, what kind?________________

Headaches/ Migraine O Yes O No

Seizures/ Epilepsy O Yes O No

Lung Disease/ Emphysema O Yes O No

Chronic Bronchitis/ Asthma O Yes O No

Emotional Problems O Yes O No If yes, what kind?________________

Nerve Problems O Yes O No If yes, what kind?________________

Other :______________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Please put a check by all past surgeries and specify the type and year that they were done

|Appendectomy |Thyroid |

|Gallbladder |Laparoscopy |

|Hysterectomy- with or without Ovaries? |Cataracts |

|Vasectomy |Knee/ Hip/ Ankle |

|Wrist |Plastic/Cosmetic |

|Tonsils |Hemorrhoid/ Rectal |

|Sinus |Prostate/ Bladder |

|Adenoids |Kidney |

|Stomach |Heart Bypass |

|Ears |Varicose Veins |

|Hernia |Cesarean section |

|Vasectomy |Other |

PLEASE LIST ALL CURENT MEDICATIONS INCLUDING MGS/STRENGTHS

1.__________________________ 2. ________________________ 3. _______________________

4._________________________ 5. ________________________ 6. _______________________

7._________________________ 8. ________________________ 9. _______________________

MEDICATION ALLERGIES:_______________________________________________________________

TYPE OF REACTIONS:___________________________________________________________________

Please fill in clearly and/or fill in bubble for appropriate items

Social History

Tobacco Use: O Yes O No If so, what kind? ________________________

Alcohol: O Yes O No

Family History

Mother has: Diabetes? O Yes O No

__ Deceased Cancer? O Yes O No If so, what kind? _________________________

__ Living Heart attack? O Yes O No

Stroke? O Yes O No

Father has: Diabetes? O Yes O No

__ Deceased Cancer? O Yes O No If so, what kind? _________________________

__ Living Heart attack? O Yes O No

Stroke? O Yes O No

Grandparents have: Diabetes? O Yes O No

Cancer? O Yes O No If so, what kind? _________________________

Heart attack ? O Yes O No

Stroke? O Yes O No

Siblings have: Diabetes? O Yes O No

Cancer? O Yes O No If so, what kind? _________________________

Heart attack? O Yes O No

Stroke? O Yes O No

Children have: Diabetes? O Yes O No

Cancer? O Yes O No If so, what kind? _________________________

Heart attack? O Yes O No

Stroke? O Yes O No

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I authorize my medical information to be released to:

Name: _______________________________________ Relationship: _______________

Name: _______________________________________ Relationship: _______________

Name: _______________________________________ Relationship: _______________

Name: _______________________________________ Relationship: _______________

___ I do not wish to have any of my medical information released to anyone but myself.

________________________ __________________________ _______________

Patient Name Patient Signature Date

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996

(HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.

• Obtain payment from third party payers.

• Conduct normal healthcare operations such as quality assessments and physician certification.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this content.

Patient Signature________________________________________________Date____________

PATIENT AUTHORIZATION

I hereby authorize Syed Hussaini, M.D. to release to my insurance company any information required, including the diagnosis and recommended course of my examination or treatment.

I understand it is the patient’s responsibility to let Syed Hussaini, M.D. know if Pre-Certification is required for any office visit, In-Patient or Out-Patient Admissions and any surgeries.

I understand that failure to notify this office may cause me increased out-of-pocket expenses such as denied claims and reduced benefits.

I hereby authorize payment directly to Syed Hussaini, M.D. for the medical and/or surgical benefits otherwise payable to me, for his services to me. I understand that I am financially responsible for the charges not covered by my insurance.

Patient

Signature _______________________________________________Date____________

NOTICE OF PRIVACY PRACTICES

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.

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPPA” provides penalties for covered entities that misuse personal health information.

As required by “HIPAA” we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes:

• Treatment, payment and health care operationsTreatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include physical examination.

• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.

• Health Care Operations including the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contract you to provide appointment reminders or information about your treatment or treatment alternatives, or other health-related benefits and services that any is of interest to you. We may leave messages for you on your personal answering device, including voice mail, unless you direct us in writing that you do not want us to do so. We may telephone and/or fax prescription requests to pharmacies regarding your medication and medication refills. Any other uses or disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we much abide by it unless you agree in writing to remove it.

• The right to reasonable request to receive confidential communication of protected health information from us by alternative means or at alternative locations.

• The right to inspect and copy your protected health information. We have to right to charge a reasonable fee for copies requested by you and made available to you.

• The right to amend your protected health information.

• The right to receive an accounting of disclosures of protected health information.

• The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to your protected health information. This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a copy of a revised Notice or Privacy Practices from this

office. You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will note retaliate against you for filing a complaint. Please contact us for the information:

For more information about HIPAA or to file a complaint:

The United States Department of Health and Human Services

Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

Toll Free: 1-877-696-6775

CONSENT FOR TREATMENT AND TO OBTAIN MEDICATION HISTORY

CONSENT FOR TREATMENT: I voluntarily consent to evaluation, treatment, diagnostic testing, medication, nursing care and/or therapy which my physician or his designees, determines to be necessary. By signing this consent, I also acknowledge that I may be sent by my physician or his designees to a facility in which they have an ownership interest. I also acknowledge and agree that in rendering care for me, my physician and his designees may choose to use products in which they have an ownership interest. I understand that I have a choice in the facilities and/or products used to provide treatment of my condition(s). I understand that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as the result of examination or treatment in this facility.

CONSENT TO OBTAIN MEDICATION HISTORY: Our medical practice has adopted an electronic medical record system in order to improve the quality of our services. This system also allows us to collect and review your “medication history”. A Medication history is a list of prescription medicines that we or other doctors have recently prescribed for you. This list is collected from a variety of sources, including your pharmacy and your health insurer.

An accurate medication history is very important to helping us treat you properly and in avoiding potentially dangerous drug interactions. By signing this consent form you give us permission to collect, and give your pharmacy and your health plan permission to disclose, information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medications used to treat mental health conditions, such as depressions. This information will become part of your medical record.

This medication history is useful guide, but it may not be completely accurate. Some pharmacies do not make drug history available to us, and the drug history from your health plan might not include drugs that you purchased without using your health insurance. Your medication history might not include over the counter medications, supplements or herbal remedies. It is still very important for us to take the time to discuss everything you are taking, and for you to point out to us any errors in your medication history.

____ I give PREMIER NEUROLOGY consent for treatment.

____ I give permission for PREMIER NEUROLOGY to obtain my medication history form my pharmacy, my health plans and my other healthcare providers.

Patient Signature__________________________________________________Date______________

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