PATIENT INFORMATION



PATIENT INFORMATIONName: ____________________________________________________________________________________________FirstMiddleLastAddress: _______________________________________________City/St/Zip: _________________________________Best Phone #: ______________________ Cell Phone #______________________ Work / Other #___________________Date of Birth: _______________________ Sex: M F Marital Status: Married Single Divorced Separated Other Your email address: ____________________________________________________________Emergency Contact Name: ________________________Relationship:_______________ Phone:____________________Primary Insurance Co.: _____________________________________________________________________________Policyholder/subscriber name: ____________________________________ Policy holder DOB: _____________________Relationship to the patient: Self Spouse Dependent Secondary Insurance Co.: ___________________________________________________________________________Policyholder/subscriber name: __________________________________ Policy holder DOB: _______________________Relationship to the patient: Self Spouse Dependent Is this workers comp?Yes NoAre you in a nursing home?YesNoAre you on hospice?Yes No Ethnic Group: Race: Language:Hispanic or LatinoAsian Other RaceNot Hispanic or LatinoAfrican American White ________________________Prefer not to discloseNative Hawaiian Prefer not toOther Pacific IslanddiscloseI hereby assign, transfer, and set over to Austin Pulmonary Consultants, PA all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization will remain valid until I revoke it by written notice. I understand that I am financially responsible for all charges whether or not they are covered by insurance.____________________________________________________________________________________Patient or Authorized SignatureDateAs we have updated our EMR system, we would like to ensure we have all of your healthcare providers in our system to ensure continuity of care. Please fill out the information below to ensure we have all the necessary information to provide the best quality of care.Provider NameSpecialty I authorize Austin Pulmonary Consultants to electronically obtain my current and past prescriptions when available electronically: Prescription List Release from Pharmacy: Yes No (This allows us to be updated with current medications) Preferred Pharmacy: _______________________________Street Name: __________________________ We now have more options available for appointment reminders. How would you like to be notified of your appointments at Austin Pulmonary? Text: ________________________________ E-mail: ________________________________ Voice: ________________________________ Please be advised that for FMLA or Disability paperwork, there is a $25 charge for completing that paperwork. _________(initial) You may receive an email asking for your feedback with your experience at our office. If you do NOT wish to participate, please initial here ______________ ______________________________ _____________________________ __________ Patient Printed Name Patient Signature DateAUTHORIZATION FOR USE AND/ OR DISCLOSURE OF INFORMATIONPatient’s Name ________________________________________DOB ____________________Person/Facility from Whom Information is to be retrievedName___________________________ Phone__________________________ Fax_______________________Recipient (Person/Entity to Whom information is to be sent)Name______________________________ Phone 512-977-0123 Fax 512-977-0126Address 3600 W. Parmer Ln Ste 106 City/State Austin,TX Zip 78727Information to be Disclosed: Reason for Disclosure:__ Demographics Sheet __ Continuation of care__ Most Recent office Note __ Consultation__ Emergency Room Reports__ Lab Results__ Radiology Reports__ Sleep Studies__ PFT__ Hospital records__ Entire medical recordI understand that:Medical information is considered Protected Health Information (PHI) under both Federal and State Privacy LawsThis authorization is and will be valid as long as I am under the care of Austin Pulmonary ConsultantsI may revoke this authorization at anytime by notifying Austin PulmonaryI authorize information to be released electronically ( e.g. fax)____________________________________ __________________________________ ______________Printed Name of Patient or Representative Signature of Patient or Representative DateI have been given an opportunity to review a copy of:Notice of Privacy Practices of Austin Pulmonary Consultants, PAOffice policies and procedures of Austin Pulmonary Consultants, PAPatient signature: ______________________________________________Date:______________Printed Name: ________________________________________________If patient cannot legally sign, please complete the section below:Patient’s personal representative’s signature: ________________________________________Printed Name: _________________________________________________Date: _____________Advance Practice Nurse Consent for Treatment This facility has on staff Advance Practice Nurses to assist in the delivery of medical care. An advance practice nurse is not a doctor. An advance practice nurse is a registered nurse who has received advanced education and training in the provision of health care. An advance practice nurse can diagnose, treat, and monitor common acute and chronic diseases as well a provide health maintenance care. In addition, the advance practice nurse may treat minor lacerations and other minor injuries. I have read the above, and hereby consent to the services of an Advance Practice Nurse for my health care needs. I understand that at any time I can refuse to see the advance practice nurse and request to see a physician. Signature: ________________________________Date: _____________________________RELEASE OF PROTECTED HEALTH INFORMATIONPLEASE READ CAREFULLYI authorize Austin Pulmonary Consultants, PA to release my protected health information to the family members or friends listed below. This is not a release of medical records. I understand that I have the right to revoke this authorization at any time. I understand the revocation will NOT apply to the information that has already been released. The information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected.Patient Name: ___________________________________________________________________I authorize the release of my protected health information to the following person(s):Name: __________________________________ Relationship: ____________________________Name: __________________________________ Relationship: ____________________________Name: __________________________________ Relationship: ____________________________Name: __________________________________ Relationship: ____________________________Name: __________________________________ Relationship: ____________________________Signed: __________________________________________________Date: ____________________Medication ListName: ________________________________________Today’s Date: _________________________________Medication Allergies and Reactions:Food Allergies and Reactions:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Iodine Allergy: YESNOPeanut Allergy:YESNOIV Contrast Allergy:YESNO NOT SUREPlease list all of the medications you take (both prescribed and over the counter). Afterthe name of the medication, please list the strength followed by the dosing instructions.ItemName of MedicationStrengthDirections123456789101112131415161718 ................
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