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Patient Intake FormPATIENT INFORMATION Male Female Marital Status: Married Single Divorce Widow _______________________ _____________________________ ____________Last Name First Name (Full or as it appears on insurance card) Middle name _________________________ ________________________ __________ ____________Address City State Zip Code_________________________________________________ ______________________ Mobile Home Email (valid email is required) Phone No. ______/_______/________ ______- ______ - _______ _______________________ Mobile Work D.O.B Social Security Alt. Phone No. __________________________________/_____________ ______________________ Mobile Home1. Name of Emergency contact & Relationship Phone No.__________________________________/_____________ ______________________ Mobile Home2. Name of Emergency contact & Relationship Phone No.Employment Status: Full Part-time Retired Care Plan: Do you have a living will or surrogate decision maker?_______Y/N________ Who is that person?_____________________Please bring those forms with you to your appointment if you would like us to have a copy on file. PHARMACY INFORMATIONPharmacy: ___________________________________ Phone No.: ________________ Fax No.: _________________Please note that all refills must be requested 72 hours in advance. Please contact your pharmacy directly to have a fax refill request sent to our office. Please contact the pharmacy to verify the refill completion.REFERRING PHYSCIAN INFORMATION__________________________________________________ Referring PCP Specialist Facility Skilled Nursing Name of Physician /Facility_______________________ ______________________ ______/______/_______ __________/________Phone No. Fax No. Date Last Seen Nurse Ext.INSURANCE INFORMATIONCheck one: Primary Secondary Tertiary Check one: PPO POS HMO MEDIGAP Policy Supplement Plan EPO Indemnity Self -FundedName of Insurance: ______________________________________________________________ Name of Policy Holder (as it appears on the card): _________________________________________ Self/Policy Holder Spouse/Policy holder (DOB______/______/______) (Social Security______-______-______) Check one: Primary Secondary Tertiary Check one: PPO POS HMO MEDIGAP Policy Supplement Plan EPO Indemnity Self -FundedName of Insurance: _______________________________________________________________ Name of Policy Holder (as it appears on the card): __________________________________________ Self/Policy Holder Spouse/Policy holder (DOB ______/______/______) (Social Security ______-______-______) I hereby state the information listed above is accurate. I authorize the release of any medical or other information necessary to process my insurance claims._________________________________________ ____/_______/_______Signature of Patient/Guardian DateCONSENT TO TREATMENT AND CONSENT TO DISCLOSURE OF PROTECTED HEALTH INFORMATIONI _________________, consent to the procedure and treatment that may be performed by physicians and other clinical staff of VEST, which may include but are not limited to physical examinations, laboratory procedure, diagnostic procedures, and medical treatment or procedures rendered for the patient under the general and special instructions of the patient’s physician.I understand that as part of my healthcare, VEST originates and maintains records that may include my health history, symptoms, examination and test results, diagnostic, treatment and any plans for future care of treatment, and information payment for the provisions of health services. I understand and authorize this information to be utilized to plan my care and treatment to bill for services provided to me, to communicate with other healthcare providers and other healthcare operations including: quality assessment through outcomes evaluations and development of clinical guidelines: reviewing competence of healthcare professionals through peer review and credentialing activities; and conducting fraud/abuse and compliance reviews. I further understand that any and all records, whether written, oral or in electronic format are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law.I understand that I may revoke this consent at any time in writing except treatment that has already taken action in reliance on this consent. I also understand that this consent is valid revoked by me in plete the following by indicating those items that you want disclosed. If all health information is to be released, then check only the first box. All health information History/Physical Exam Past/Present Medications Lab Results Physician’s Orders Patient Allergies Operation Reports Progress Notes Discharge Summary Diagnostic Test Reports Pathology Reports Billing Information Radiology Reports & Images Consultation Reports EKG/Cardiology Reports Other: _______________Your Initials are required to release the following information:___ Mental Health Records (excluding psychotherapy notes)___ Drug, Alcohol, or Substance Abuse Records___ HIV/AIDS Test results/TreatmentName of Patient or Individual_____________________ _________________ _____ _____/_____/_____Last Name First Name Middle DOB (patient)____________________________Another name used________________________________Print Name or Legal Representative_________________________________ ____/_____/______Patient Signature or Legal Representative DateNotice of Concerning ComplaintsComplaints about physicians, as well as other licenses and registrants of the Texas State Board of Medical Examiners, including physician assistants, may be reported for investigation at one of the following addresses:Texas State Board of Medical ExaminersAttention: Investigations 333 GuadalupeTower 3Suite 610Austin, Texas 78768-2018PATIENT FINANCIAL RESPONSIBILITY ________Initial Methods of payment accepted: Visa, MasterCard, Discover, Cash, and Checks. Payments of co pays are due at time of service._______ Initial Individual/Group Insurance: As a courtesy to you, we will submit the appropriate claims to your insurance company(s). If your insurance company(s). If your insurance requires an employee claim form, or any other information from your insurance company. Therefore, you are ultimately responsible for payments of all charges. It is your responsibility to resolve disputes between you and your insurance company regarding deductibles, co-payments, coverage charges, secondary insurance, “usual and customary” charges, and use of any special forms. We require that your account is paid in full within 60 days of the date of service, regardless of the status of your insurance claim. If you need an extended payment plan, please contact our office at 210-369-9151. _______ Initial Medicare: We are a participating provider of all charges at the time services are rendered. For your convenience, appropriate claims will be sent to your Medicare Supplemental insurance. Any deductible, co-payment amounts of routine non-covered services are your responsibility and will be billed to you after Medicare and your supplemental insurance has processed and paid appropriate benefits. _______ Initial No Insurance Coverage: We require payment of all charges at the time services are rendered. A self pay discount is offered when payment is made at the time of service. If you are unable to pay at the time of service, please contact our Billing Department to make payment arrangements. _______ Initial Financial Assistance: We will be pleased to assist you with any questions requiring available payment options. We are committed to providing services to those who may need financial assistance. If you have questions regarding financial assistance or would like a financial assistance application, please contact our BILLING office 210-267-8079. _______ Initial Return Check Policy: There is a $25.00 service charge on all returned checks. *After received a returned check our office will only accept cash, money order, or credit card. _______ Initial Cancelation/No Show Policy: While understanding there may be times when you miss an appointment due to emergencies or obligations, our office requires at least 24 hour notice on all cancelled appointments. Our office charges a fee of $25.00 for appointment not cancelled or rescheduled 24 hours in advance. Cancellation/No show fees must be paid prior to your next appointment.ASSIGNMENT OF BENEFITS_______ Initial Insurance Authorization/Release: I hereby authorize the physician/provider to release any and all information necessary concerning my diagnosis and treatment for the purpose of securing payment from my insurance company; and thereby authorize payment of the insurance benefits directly to the physician for any all services rendered._______ Initial Medicare Authorization / Release: I request that payment of authorized benefits to be made on my behalf to the physician/provider for any and all services provided to me by that physician/provider. I hereby authorize any holder of medical information about me to release to the Centers for Medicare Services and its agents any information needed to determine these benefits or the benefits payable for related services.My signature below indicates that I have read and understood the foregoing information relative to my responsibility for the services provided as well as authorizing the release of medical information as required processing claims and benefits to which I am entitled._____________________________________ _______________Print Name Date ______________________________________ _______________Patient SignatureDate of Birth_____________________Patient SS#PATIENT MEDICAL INFORMATION Please list your current medications:______________________________________________________________________________________________________________________________________________________________________________________________________________________________Past Medical History:AnemiaAnticoagulation TherapyAnxiety DisorderAortic AneurysmArrhythmiaArthritisAsthmaAtrial FibrillationAtrial FlutterBleeding DisorderBlood DisorderBlood ClotCOPDCancerCardiomyopathyCarotid DiseaseClotting DisorderCongenital Heart DiseaseCongestive Heart Failure (CFH)Coronary Artery DiseaseDeep Vein ThrombosisDepressionDiabetesEpilepsy/SeizuresGERD/RefluxGastrointestinal DiseaseGenitourinary DiseaseHeart Attack (MI)Heart DiseaseHeart MurmurHepatitisHigh CholesterolHistory of Blood ThinnersHypertensionKidney DiseaseLiver DiseaseLung DiseaseNeurological DisordersPacemakerPeripheral Arterial DiseasePulmonary EmbolismRestless Leg SyndromeSleep ApneaSleep DisordersStrokeThyroid DiseaseThyroid ProblemsTransplantsUlcersVaricose VeinsWarfarin ManagementSignificant Family Medical History:Anemia Relation:________________Arthritis Relation:________________Asthma Relation:________________Bleeding Disorder Relation:________________COPD Relation:________________Cancer Relation:________________Congestive Heart Failure (CFH) Relation:________________DepressionRelation:________________DiabetesRelation:________________Epilepsy/SeizuresRelation:________________GERD/RefluxRelation:________________Gastrointestinal DiseaseRelation:________________Heart Attack (MI)Relation:________________Heart MurmurRelation:________________HypertensionRelation:________________Kidney/Liver/Lung DiseaseRelation:________________Neurological DisordersRelation:________________Sleep DisordersRelation:________________StrokeRelation:________________ ................
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