New-Patient-Packet-v2.pdf



1976 E Baseline Rd, Suite 101, Tempe, AZ 85283Phone (480) 939-3037 - Fax (480) 939-3173Hussam Seif-Eddeine, MDNew Patient RegistrationPatient Name:Date of Birth:SSN:Street Address:City, State, Zip:Home phone: Cellphone: Gender:Marital status: Race: Ethnicity: Hispanic or Latino Not Hispanic or LatinoPreferred Language: E-mail address:Primary Care Physician:Referring Physician:Address:Address:Phone Number: Phone Number: Pharmacy:Mail Order Pharmacy:Address: Address:Phone Number: Phone Number: Primary Insurance:Secondary Insurance:ID #ID #Group #Group #Address: Address: Phone Number:Phone Number:Name of Primary Insured:DOB:Phone Number: SSN:Relationship to Patient:Employer:Emergency Contact:Relation to Patient:Phone Number:Address:Do you have a living will?Do you have a power of attorney? Name: Date:Signature:Relationship to patient:1976 E Baseline Rd, Suite 101, Tempe, AZ 85283Phone (480) 939-3037 - Fax (480) 939-3173Hussam Seif-Eddeine, MDMEDICAL HISTORYPatient Name:Date of Appointment:DOB: SSN: Reason for today’s visit: Are your symptoms related to an accident?Is a legal case pending?Allergies:Name of medicine or product:Description of reaction:Current Medications: Name of medicationDosage and times per dayOver the counter medicines, vitamins, or herbal supplementsPrior Meds used for current problem:Name:Date:REVIEW OF SYSTEMS:General / Constitutional:change in appetite, fever, weakness, other:Allergy / Immunology: hives, itching, rash, other:Ophthalmologic:blurry vision, discharge, red eye. Patient complains of double vision, other:Endocrine:cold intolerance, hair loss, irregular menses, other:Respiratory:chronic cough, shortness of breath, sputum production, other:Breast:bloody nipple discharge, breast pain, breast swelling, other:Cardiovascular:pain, chest pain with exertion, irregular heartbeat, other:Gastrointestinal:abdominal pain, diarrhea, rectal bleeding, other: Hematology:easy bleeding, easy bruising, recent transfusion, other:Gynecology:abnormal bleeding, hot flashes, pelvic pain, other:Genitourinary:abdominal pain / swelling, blood in the urine, frequent urination, other:Musculoskeletal:Patient denies arthritis / arthralgia, joint stiffness, swollen joints, other:Peripheral Vascular:blanching of skin, cold extremities, decreased sensation in extremities, other:Podiatric:ankle pain, foot pain, sole pain, other:Skin:blistering of skin, changing moles, skin lesion(s), other:Neurologic:dizziness, gait abnormality, headache, seizures, other:Psychiatric: delusions, depressed mood, difficulty sleeping, other:PAST MEDICAL HISTORY:General / Constitutional:Allergy / Immunology: Ophthalmologic:Endocrine:Respiratory:Breast:Cardiovascular:Gastrointestinal:Hematology:Gynecology:Genitourinary:Musculoskeletal:Peripheral Vascular:Podiatric:Skin:Neurologic:Psychiatric: SURGICAL HISTORY:Type of Surgery and reasonYearFAMILY HISTORY:Do you have any family members with similar problems as you? YNDiseaseFamily memberHeadachesSeizuresStrokeBrain AneurysmBleeding disordersNeuropathyAutoimmune diseaseHigh blood pressureHigh cholesterolDiabetesHeart diseaseSOCIAL HISTORY:Marital statusTobacco useType: Amount/day: #years: Year quit:Alcohol useType: Amount/day: #years: Year quit:Recreational DrugsType: Amount/day: #years: Year quit:Current occupation:PRIOR WORKUP: Type of studyApproximate dateFacilityResultName: Date:Signature:Relationship to patient:1976 E Baseline Rd, Suite 101, Tempe, AZ 85283Phone (480) 939-3037 - Fax (480) 939-3173Hussam Seif-Eddeine, MDConsent to Obtain External Prescription HistoryI, , , whose signature appears below, authorize Arizona Neurology Care and its affiliated providers to view my external prescription history via the RxHub service.I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by your provider and staff.My signature certifies that I read and understand the scope of this consent and that I authorize the access.Name:Date:Signature:Relationship to patient: 1976 E Baseline Rd, Suite 101, Tempe, AZ 85283Phone (480) 939-3037 - Fax (480) 939-3173Hussam Seif-Eddeine, MDFinancial PolicyPLEASE INITIAL ALL OF THE FOLLOWING___ Unless 24-hour notice is given, I understand that there will be a $25 charge for appointment ($50 charge in case of procedures or infusions).___ I understand that I am financially responsible for any copayments, deductibles, coinsurance, and all charges which are not covered by my insurance.____ I understand that verification of coverage does not guarantee payment of benefits. My insurance company determines insurance benefit payments. I understand I will be responsible for that portion of all charges not covered by my insurance.___ I understand that I am responsible for all charges if it is determined that the insurance information, I have provided is not correct. ___ Due to the large number of insurance plans and policies, it is the patient's responsibility to be aware of the services that are covered by your plan. Please call your insurance company for an explanation of your benefits.___ I understand that I am responsible for my co-pay at the time of my visit. We accept cash, all major credit cards, and personal checks.___ I understand that there is a $25 charge for a Non-Sufficient Funds (NSF) check.___ I understand that there is a $25-$300 charge for all forms deemed necessary and filled out by the Physician OR Nurse Practitioner (e.g. Disability, FMLA, etc.) depending on number of pages. ___ I understand that if I need an appointment with the Doctor or Nurse Practitioner to fill out these forms we will not bill the insurance for the appointment of form completion. The form fee must be paid at time of service or upon completion of forms.___ I understand that Arizona Neurology Care does not accept liens; worker's compensation, or MVA/auto claims and that I am responsible for any insurance claims denied as such. If my medical insurance denies or takes back any monies provided, I understand that I am responsible to pay all claims in full.___ If my account is not paid in full within 90 days, I understand that it will be considered delinquent. No additional appointments will be made for patients with delinquent accounts until they are brought current, and delinquent accounts will be turned over to a collection agency.___ I hereby authorize the release of information that may be necessary in the processing of any insurance claims.___ I hereby authorize my insurance company to make payment directly to: Arizona Neurology Care.___ I have read, and I understand the above Financial Policy and I agree to abide by its terms. No changes to this policy by the patient will be acknowledged. Questions may be directed to the billing office.Name:Date:Signature:Relationship to patient:1976 E Baseline Rd, Suite 101, Tempe, AZ 85283Phone (480) 939-3037 - Fax (480) 939-3173Hussam Seif-Eddeine, MDPatient Communication and ConsentThere are occasions when Arizona Neurology Care may have to call to discuss Confidential Protected Health Information. Please let us know how you would like us to get this information to you:Ok to call my home/cell phone and leave a message on the answering machineOk to call my home but DO NOT leave a messageDo Not call my home phone but call this number () _____-_______Do Not leave message with family memberWho may receive information regarding your Protected Health Information?NameDate of BirthRelationshipI have received a copy of the Notice of Privacy Practices from this provider and authorize the above list of persons who may receive my Protected Health Information. I may revoke this at any time by giving written notification to Arizona Neurology Care.I hereby authorize Arizona Neurology Care to release any medical or incidental information to my referring physician or any other physicians who have been or may become involved with my care.I also authorize the release of information that may be necessary in the processing of any insurance claims.I also authorize the release of any medical records including pharmacy records to Arizona Neurology Care upon request.Name:Date:Signature:Relationship to patient:1976 E Baseline Rd, Suite 101, Tempe, AZ 85283Phone (480) 939-3037 - Fax (480) 939-3173Hussam Seif-Eddeine, MDHIPAA Privacy and Release of Information AuthorizationI, , hereby authorize Arizona Neurology Care and its affiliates, its employees and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address, social security number, Member ID number) for the purpose of helping me to resolve claims and health benefit coverage issues.I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws.I understand that I have a right to revoke this authorization by providing written notice to. However, this authorization may not be revoked if, it's employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization.I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.I have been advised of this practice's Privacy Practices, Release of Billing Information policy, Assignment of Benefits policy, and grant the practice Medication History Authority.If applicable, Legal Representatives sign below:By signing this form, I represent that I am the legal representative of the Member identified above and will provide written proof (e.g., Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the Member's behalf with respect to this authorization form. Name:Date:Signature:Relationship to patient: ................
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