Dynamic.cdn.smartwcm.com
*
| |
|Patient Name: |
|[pic] |
| |
|Date of Birth: |
| |
|[pic] |
| |
| |
| |
|Dear New Patient, |
| |
|Thank you for choosing Dr. Ashwani Srivastava as your physician. |
|We are looking forward to meeting all of your medical needs. |
| |
|If you have any questions or concerns before your scheduled visit |
|please do not hesitate to call our office. |
| |
|We have enclosed a patient information package. Please answer all |
|questions so that the physician may deliver the best course of treatment and prevention for you. |
| |
| |
| |
|In addition to the completed information forms please remember to |
|bring with you: |
| |
| |
|[pic] |
|Insurance Card |
| |
|[pic] |
|Valid I.D. or Driver's License |
| |
|[pic] |
|All Medications |
| |
|[pic] |
|Medical Records |
| |
| |
| |
|New Patient General Information |
|Please Answer All Questions |
| |
| |
|Today’s Date: |
| |
|Referred By: |
| |
| |
| |
| |
|MM / DD / YYYY |
| |
|Last Name: |
| |
|First Name: |
| |
| |
|MI: |
| |
| |
| |
| |
| |
| |
|Date of Birth: |
|* |
| |
|Age: |
|* |
| |
| |
|SEX |
|[pic] [pic] |
|MARITAL STATUS |
|[pic][pic][pic][pic] |
| |
| |
| |
|MM / DD / YYYY |
| |
|Social Security Number: |
| |
|- |
| |
| |
|- |
| |
| |
|Driver License#: |
| |
| |
| |
| |
| |
| |
| |
|Address: |
| |
|Apt#: |
| |
| |
| |
| |
| |
| |
|City: |
| |
|State: |
| |
|Zip Code: |
| |
| |
| |
| |
| |
| |
|Home Phone: |
| |
|Work Phone: |
| |
|Alternate Phone: |
| |
| |
| |
| |
| |
| |
|In Case of Emergency Contact: |
| |
|Relationship: |
| |
|Phone# |
| |
|1. |
| |
| |
| |
| |
| |
| |
|2. |
| |
| |
| |
| |
| |
| |
|* |
| |
| |
| |
|PRIMARY INSURANCE |
| |
| |
| |
|Insured's Name: |
| |
| |
| |
|Relation: |
| |
| |
| |
|Phone #: |
| |
| |
| |
| |
| |
|Insured Address: |
| |
| |
| |
|City: |
| |
| |
| |
|State: |
| |
|Zip: |
| |
| |
| |
| |
| |
|Employer's Name: |
| |
| |
| |
|Employer Address: |
| |
| |
| |
| |
| |
|Employer Phone: |
| |
| |
| |
|Insurance Name: |
| |
| |
| |
| |
| |
|Insured ID: |
| |
| |
| |
|Policy or Group Number: |
| |
| |
| |
| |
| |
| |
| |
|SECONDARY INSURANCE |
| |
| |
| |
|Insured's Name: |
| |
| |
| |
|Relation: |
| |
| |
| |
|Phone #: |
| |
| |
| |
| |
| |
|Insured Address: |
| |
| |
| |
|City: |
| |
| |
| |
|State: |
| |
|Zip: |
| |
| |
| |
| |
| |
|Employer's Name: |
| |
| |
| |
|Employer Address: |
| |
| |
| |
| |
| |
|Employer Phone: |
| |
| |
| |
|Insurance Name: |
| |
| |
| |
| |
| |
|Insured ID: |
| |
| |
| |
|Policy or Group Number: |
| |
| |
| |
| |
| |
| |
| |
|I understand that if any of the insurance information I have provided is incorrect or I fail to notify the office of any insurance changes that I am responsible for all |
|physician charges and non-covered medical service. |
| |
|I hereby authorize the release of any medical information necessary for the processing of insurance. I hereby assign all medical and/or surgical benefits to which I am |
|entitled to Internal Medicare Associates of South Dallas, P.A. This agreement will remain in effect until revoking by me in writing. A photocopy of this agreement is to |
|be considered as an original. |
| |
|I have received the Notice of Privacy Practices. |
| |
|OUR OFFICE POLICY STATES THAT PAYMENT FOR SERVICES IS REQUIRED AT TIME OF VISIT |
| |
|Patient Signature: |
| |
| |
| |
| |
|* |
|PATIENT HISTORY |
|(1 of 2) |
| |
|Today’s Date: |
| |
|Referred By: |
| |
| |
| |
| |
| |
| |
|Social Security Number: |
| |
|Last Name: |
| |
|First Name: |
| |
|MI:: |
| |
| |
| |
|- |
| |
| |
|- |
| |
| |
|Reason for Visit: |
| |
| |
| |
| |
| |
| |
| |
|Do you live alone? |
|[pic] |
|[pic] |
| |
|Do you drive? |
|[pic] |
|[pic] |
| |
|Do you have a medical power of attorney? |
|[pic] |
|[pic] |
| |
|Do you have a living will? |
|[pic] |
|[pic] |
| |
|Do you use a walker, cane or a wheelchair |
|[pic] |
|[pic] |
| |
|Do you have a hospital bed at home? |
|[pic] |
|[pic] |
| |
|Do you smoke? |
|[pic] |
|[pic] |
| |
|Do you have hypertension |
|D |
|[pic] |
|[pic] |
| |
|(high blood pressure) |
| |
| |
| |
|Do you have diabetes/ thyroid disorder |
|[pic] |
|[pic] |
| |
|or other endocrine disorder? |
| |
| |
| |
|Do you have any immune disorders? |
|[pic] |
|[pic] |
| |
|Do you have poor immune healing? |
|[pic] |
|[pic] |
| |
|Edema or excessive fluid retention? |
|[pic] |
|[pic] |
| |
|Thyroid, diabetes or other endocrine |
| |
| |
| |
|Disorder including insulin resistance? |
|[pic] |
|[pic] |
| |
|Do you have sleep apnea? |
|[pic] |
|[pic] |
| |
|Hyperlipidemia (high cholesterol) |
|[pic] |
|[pic] |
| |
|Cancer, Please specify:_______________ |
|[pic] |
|[pic] |
| |
|Do you have any stents, or a pacemaker? |
|[pic] |
|[pic] |
| |
|Do you have oxygen at home? |
|[pic] |
|[pic] |
| |
| |
| |
|* |
|LIST ALL SPECIALISTS YOU SEE |
| |
|Doctor’s Name: |
|Reason: |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|Do you have upper respiratory disorders? |
|[pic] |
|[pic] |
| |
|Do you have renal (kidney) disease? |
|[pic] |
|[pic] |
| |
|Orthopedic or muscle disorder, including |
|[pic] |
|[pic] |
| |
|fracture, joint disorder? |
| |
| |
| |
|Do you have asthma? |
|[pic] |
|[pic] |
| |
|Do you have emotional disorders? |
|[pic] |
|[pic] |
| |
|Do you have glaucoma? |
|[pic] |
|[pic] |
| |
|Rheumatoid arthritis, lupus, or connective |
|[pic] |
|[pic] |
| |
|tissue diseases? |
| |
| |
| |
|Do you have a chemical dependency? |
|[pic] |
|[pic] |
| |
|Cardiovascular (heart or artery) disease? |
|[pic] |
|[pic] |
| |
|Do you have osteoporosis / osteopenia? |
|[pic] |
|[pic] |
| |
|Any other illness, disease, disorder, or |
|[pic] |
|[pic] |
| |
|Medical condition? __________________ |
| |
| |
| |
| |
| |
|* |
| |
| |
| |
|WOMEN’s HEALTH |
| |
|Last Period: |
|#_Pregnancies: |
|#_Deliveries: |
|#_Miscarriages: |
| |
| |
| |
| |
| |
| |
|* |
| |
| |
| |
|PAST MEDICAL AND SURGICAL HISTORY |
|*please list all surgeries – including blood transfusions* |
|Date: |
|Hospital/Location |
|Doctor: |
|Reason: |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|Have you had any of the following surgeries? |
| |
|[pic] |
|[pic] |
|[pic] |
|[pic] |
|[pic] |
|[pic] |
| |
|[pic] |
|[pic] |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|CHECK CONDITIONS THAT MAY APPLY TO YOU |
|[pic] |
|ADS/HIV |
|[pic] |
|Cataracts |
|[pic] |
|Hernia: Inguinal / Hiatal |
|[pic] |
|Prostate Problems |
|[pic] |
|Rheumatoid Arthritis |
| |
| |
|[pic] |
| |
|[pic] |
| |
|[pic] |
|Herpes (shingles) |
|[pic] |
|Psychiatric Care |
|[pic] |
|Cancer |
| |
| |
|[pic] |
|Alcoholism |
|[pic] |
| |
|[pic] |
|High Blood Pressure |
|[pic] |
| |
|[pic] |
|Anxiety disorder |
| |
| |
|[pic] |
|Anemia (low blood count) |
|[pic] |
|Depression |
|[pic] |
|High Cholesterol |
|[pic] |
|Stroke |
|[pic] |
|Seizure disorder |
| |
| |
|[pic] |
|Anorexia (loss of appetite) |
|[pic] |
|Diabetes |
|[pic] |
|Kidney Disease |
|[pic] |
|Suicide Attempt |
|[pic] |
|Osteoporosis |
| |
| |
|[pic] |
|Appendicitis |
|[pic] |
|Emphysema |
|[pic] |
|Liver Disease |
|[pic] |
|Thyroid Problems |
|[pic] |
|Lupus |
| |
| |
|[pic] |
|Arthritis |
|[pic] |
|Epilepsy / Seizures |
|[pic] |
|Migraine / Headache |
|[pic] |
|Arrhythmia (irregular heartbeat) |
| |
| |
|[pic] |
|Asthma |
|[pic] |
|Glaucoma |
|[pic] |
|Mitral Valve Prolapse |
|[pic] |
|Ulcers |
|[pic] |
|Alzheimer's |
| |
| |
|[pic] |
|Bleeding Disorder |
|[pic] |
|Goiter (enlarged thyroid) |
|[pic] |
|Multiple Sclerosis |
|[pic] |
|STD |
|[pic] |
|Dialysis |
| |
| |
|[pic] |
| |
|[pic] |
|Gout |
|[pic] |
|Pacemaker |
|[pic] |
|Atrial Fibrillation |
|[pic] |
|Tuberculosis |
| |
| |
|[pic] |
| |
|[pic] |
|Heart Disease |
|[pic] |
|Pneumonia |
|[pic] |
|Circulation Disorder |
|[pic] |
|Other |
| |
| |
| |
|[pic] |
|Multiple Myeloma |
|[pic] |
|Hepatitis |
|[pic] |
|Polio/Mumps/Chicken Pox |
|[pic] |
|Reflux Disease |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|Please list all allergies or adverse reactions (medicine, food, etc.): |
| |
| |
| |
| |
| |
|* |
|PATIENT HISTORY |
|(2 of 2) |
| |
| |
| |
|PHARMACY |
| |
|Name: |
| |
| |
|Location: |
| |
| |
|Phone: |
| |
| |
|FAX: |
| |
| |
|MailOrder: |
| |
| |
|* |
|PLEASE LIST ALL MEDICATIONS |
|(continue list on reverse) |
| |
|*include dosage, time of day, over-the-counter meds, anti-inflammatory, blood thinners, vitamins, herbs* |
| |
|Name: |
|Dose: |
|AM: |
|Noon: |
|PM: |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|[pic] |
|[pic] |
|[pic] |
| |
| |
| |
|HABITS |
| |
| |
|TOBACCO |
|ALCOHOL |
|ILLICIT |
|DRUGS |
|COFFEE |
| |
|None? |
| |
| |
| |
| |
| |
|How much? |
| |
| |
| |
| |
| |
|How long? |
| |
| |
| |
| |
| |
|When did you quit? |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|* |
| |
|FAMILY HISTORY |
| |
|Relationship? |
|Age? |
|Living? |
|If applicable, |
|cause of death. |
| |
|Father |
| |
|[pic] |
| |
| |
|Mother |
| |
|[pic] |
| |
| |
|[pic] |
|Brother |
|[pic] |
|Sister |
| |
| |
| |
|[pic] |
| |
| |
|[pic] |
|Brother |
|[pic] |
|Sister |
| |
| |
| |
|[pic] |
| |
| |
|[pic] |
|Brother |
|[pic] |
|Sister |
| |
| |
| |
|[pic] |
| |
| |
|[pic] |
|Brother |
|[pic] |
|Sister |
| |
| |
| |
|[pic] |
| |
| |
|[pic] |
|Brother |
|[pic] |
|Sister |
| |
| |
| |
|[pic] |
| |
| |
| |
|Is there any history of the following in your family? |
|(Please check boxes below) |
|[pic] |
|Diabetes |
|[pic] |
|Cancer |
|[pic] |
|High Blood Pressure |
| |
|[pic] |
|Colon Polyps |
|[pic] |
|Heart Disease |
|[pic] |
|High Cholesterol |
| |
| |
| |
| |
| |
| |
| |
| |
|* |
|CANCERS: |
|[pic] |
|Breast |
|[pic] |
|Prostate |
|[pic] |
|Prostate |
| |
| |
|[pic] |
|Ovarian |
|[pic] |
|Colon |
|[pic] |
|Colon |
| |
| |
|[pic] |
|Lung |
|[pic] |
|Other |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|Have you had these? |
| |
| |
| |
| |
| |
|[pic] |
|Pneumonia Vaccine |
|[pic] |
|Stress test |
|[pic] |
|Colonoscopy |
| |
|[pic] |
|Flu Shot |
|[pic] |
|MRI |
|[pic] |
|Pap smear |
| |
|[pic] |
|Hepatitis Vaccine |
|[pic] |
|CAT scan |
|[pic] |
|Prostate exam |
| |
|[pic] |
|Tetanus Shot |
|[pic] |
|Sonogram |
|[pic] |
|Bone Density |
| |
|[pic] |
|Shingles Shot |
|[pic] |
|X-Ray |
|[pic] |
| |
| |
|[pic] |
|Prevnar 13 |
|[pic] |
|Mammogram |
|[pic] |
| |
| |
|* |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|* |
|GENERAL REVIEW OF SYSTEMS |
|check the boxes if yes only |
| |
| |
|GENERAL |
| |
|[pic] |
|Chills Fever |
| |
| |
|[pic] |
|Depression |
| |
| |
|[pic] |
|Fainting / dizziness |
| |
| |
|[pic] |
|Loss of weight |
| |
| |
|[pic] |
|Sweating |
| |
| |
|[pic] |
|Difficulty sleeping |
| |
| |
|[pic] |
|Decreased energy |
| |
| |
|[pic] |
|Shortness of Breath |
| |
| |
|[pic] |
|Passed Out / Faint |
| |
| |
|[pic] |
|Dizziness |
| |
| |
|[pic] |
|Vertigo |
| |
| |
| |
|EYES / EARS / NOSE / THROAT |
| |
|[pic] |
|Blurred vision |
| |
| |
|[pic] |
|Double vision |
| |
| |
|[pic] |
|Eye pain |
| |
| |
|[pic] |
|Decrease hearing |
| |
| |
|[pic] |
|Ringing in ears |
| |
| |
|[pic] |
|Earache |
| |
| |
|[pic] |
|Runny nose |
| |
| |
|[pic] |
|Sinus problems |
| |
| |
|[pic] |
|Mouth ulcers |
| |
| |
|[pic] |
|Persistent cough |
| |
| |
| |
|CARDIOVASCULAR |
| |
|[pic] |
|Chest pain |
| |
| |
|[pic] |
|High blood pressure |
| |
| |
|[pic] |
|Shortness of breath |
| |
| |
|[pic] |
|Irregular heartbeats |
| |
| |
|[pic] |
|Palpitation |
| |
| |
|[pic] |
|Swollen ankles |
| |
| |
|[pic] |
|Leg cramps |
| |
| |
|[pic] |
|Heart murmur |
| |
| |
|[pic] |
|Poor Circulation |
| |
| |
| |
| |
|RESPIRATORY |
| |
|[pic] |
|Coughing |
| |
| |
|[pic] |
|Coughing blood / Severe |
| |
| |
|[pic] |
|Tuberculosis |
| |
| |
|[pic] |
|Asthma |
| |
| |
| |
|GASTROINTESTINAL |
| |
|[pic] |
|Poor appetite |
| |
| |
|[pic] |
|Trouble Swallowing |
| |
| |
|[pic] |
|Pain with swallowing |
| |
| |
|[pic] |
|Indigestion |
| |
| |
|[pic] |
|Heartburn |
| |
| |
|[pic] |
|Nausea / vomiting |
| |
| |
|[pic] |
|Abdominal pain |
| |
| |
|[pic] |
|Diarrhea |
| |
| |
|[pic] |
|Ulcer |
| |
| |
|[pic] |
|Liver Disease |
| |
| |
|[pic] |
|Hepatitis |
| |
| |
|[pic] |
|Gallbladder disease |
| |
| |
|[pic] |
|Lactose intolerant |
| |
| |
|[pic] |
|Hemorrhoids |
| |
| |
|[pic] |
|Bloody stools |
| |
| |
|[pic] |
|GENITOURINARY |
| |
|[pic] |
|Trouble urinating |
| |
| |
|[pic] |
|Blood in urine |
| |
| |
|[pic] |
|Frequent urination |
| |
| |
|[pic] |
|Loss of bladder control |
| |
| |
|[pic] |
|Sexual problems |
| |
| |
|[pic] |
|Stones |
| |
| |
|[pic] |
|NEUROLOGICAL |
| |
|[pic] |
|Numbness / tingling |
| |
| |
|[pic] |
|Partial paralysis |
| |
| |
|[pic] |
|Seizures |
| |
| |
|[pic] |
|Headaches |
| |
| |
| |
| |
|MUSCOLSKELETAL |
| |
|[pic] |
|Swollen joints |
| |
| |
|[pic] |
|Joint stiffness |
| |
| |
|[pic] |
|Muscle pain |
| |
| |
|[pic] |
|Arthritis |
| |
| |
|[pic] |
|Back pain |
| |
| |
|[pic] |
|Rash / Itching |
| |
| |
|[pic] |
|Breast mass / discharge |
| |
| |
| |
|HEMATOLOGICAL / LYMPHATIC |
| |
|[pic] |
|Anemia |
| |
| |
|[pic] |
|Tumor / cancer |
| |
| |
|[pic] |
|Bruise / bleed easily |
| |
| |
| |
|ENDOCRINE |
| |
|[pic] |
|History of goiter |
| |
| |
|[pic] |
|Problems with calcium |
| |
| |
|[pic] |
|Problems with glands |
| |
| |
| |
|ALLERGIC / HEMATOLOGIC |
| |
|[pic] |
|Hay Fever |
| |
| |
|[pic] |
|Hives |
| |
| |
|[pic] |
|Food Allergy |
| |
| |
|[pic] |
|Other |
| |
| |
| |
|OTHER |
| |
|[pic] |
| |
| |
| |
|[pic] |
| |
| |
| |
|[pic] |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|* |
| |
|**If the packet was not completed by the patient please write your name below – disregard if you are the patient** |
| |
| |
|Completed By: |
| |
| |
|Relationship to Patient: |
| |
| |
| |
| |
| |
| |
| |
| |
|* |
| |
|* |
| |
|* |
| |
| |
|AUTHORIZATION TO RELEASE INFORMATION |
| |
| |
| |
|I authorize Internal Medicine Associates of South Dallas, P.A. to furnish requested information from the patient's medical |
|and other records to 1) any insurance company or third party for the purpose of obtaining payment on the account of |
|Internal Medicine Associates of South Dallas, P.A. 2) any other person(s) or entities financially responsible for the |
|patient's care or treatment, and 3) representatives of local, state, or federal agencies in accordance with law. Such |
|information may include, but not be limited to, information concerning communicable diseases such as Acquired Immune |
|Deficiency Syndrome (AIDS). I authorize the release of information from or the review of the patient's records for the |
|purpose of conducting any medical audit, utilization reviews, or quality assurance reviews. I authorize Internal Medicine |
|Associates of South Dallas, P.A. to release information from or copies of the patient's medical record to any referring physician or to any skilled nursing facility or |
|other health care facility to which patient may be transferred. |
| |
| |
| |
|Patient’s Signature: |
| |
| |
|Date: |
| |
| |
| |
| |
| |
| |
| |
| |
|ASSIGNMENT OF INSURANCE BENEFITS |
| |
| |
| |
|In consideration of services rendered, I hereby transfer and assign Internal Medicine Associates of South Dallas, P.A. all |
|rights, title, and interest in any payment due to me for services described in any policy or policies of insurance. I |
|understand that I am responsible for providing Internal Medicine Associates of South Dallas, P.A. all insurance |
|information at the time of my visit to allow verification prior to my visit, and that regardless of my assigned insurance |
|benefits, I am responsible for the total charge for services rendered. |
| |
| |
| |
|Patient’s Signature: |
| |
| |
|Date: |
| |
| |
| |
| |
| |
| |
| |
| |
|ALL PPO, HMO, MEDICARE, AND MEDICAID PATIENTS |
| |
| |
|I understand that the physician(s) will file any charges for services to insurances carriers who they are providers for. I |
|hereby assign to the physician(s) all payments otherwise payable to me for any medical services rendered for my care and |
|I agree to pay any co-payment or deductibles as deemed appropriate by my insurance carrier. |
| |
| |
| |
|Patient’s Signature: |
| |
| |
|Date: |
| |
| |
| |
| |
| |
| |
| |
| |
|ALL CASH AND PRIVATE INSURANCE PATIENTS |
| |
| |
| |
|ALL CASH PATIENTS WILL BE EXPECTED TO PAY FOR ALL CHARGES AT THE TIME OF SERVICE |
| |
| |
| |
|*** PLEASE NOTE THAT CHECKS ARE NOT ACCEPTED FOR PATIENTS WITH NO INSURANCE*** |
| |
| |
| |
|All private insurance patients will be expected to pay for charges at time of service. As a courtesy, charges can be filed |
|with your insurance carrier for reimbursement directly to you |
| |
| |
| |
|Patient’s Signature: |
| |
| |
|Date: |
| |
| |
| |
| |
|* |
| |
| |
|HIPPA Consent for Purposes of Treatment, Payment, and Healthcare Operations |
| |
| |
| |
|I consent to the use disclosure of my protected health information by Internal Medicine Associates of South Dallas, P.A. for the purpose of diagnosis or providing |
|treatment to me, obtaining payment for my healthcare bills or to conduct health care operations Internal Medicine Associates of South Dallas, P.A. I understand that |
|diagnosis or treatment of me by Dr. Ashwani Srivastava may be upon my consent as evidence by my signature on this document. |
| |
|I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare |
|operations of the practice. Internal Medicine Associates of South Dallas, P.A. is not required to agree to the restrictions that I may request. However, if Internal |
|Medicine Associates of South Dallas, P.A. agrees to a restriction that I request, the restriction is binding on Internal Medicine Associates of South Dallas, P.A. and |
|Dr. Ashwani Srivastava. |
| |
|I have the right to revoke this consent, in writing, at any time, except to the extent that Internal Medicine Associates of South Dallas, P.A. or Dr. Ashwani Srivastava|
|has taken action in reliance on this consent. |
| |
|My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another |
|health care provider, a health plan, my employer or a health care clearinghouse, this protected health information relates to my past, present, or future physical or |
|mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. |
| |
|I understand I have a right to review Internal Medicine Associates of South Dallas, P.A. Notice of Privacy Practices prior to signing this document. The Internal |
|Medicine Associates of South Dallas, P.A. Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and |
|disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performances of health care operations of Internal Medicine|
|Associates of South Dallas, P.A. The Notice of Privacy Practices for Internal Medicine Associates of South Dallas, P.A. is also provided in the checkout office. This |
|Notice of Privacy Practices also describes my rights and the Internal Medicine Associates of South Dallas, P.A. duties with respect to my protected health information. |
| |
|Internal Medicine Associates of South Dallas, P.A. reserves the right to change the privacy practices that are described in the Notice of Privacy practices. I may |
|obtain a revised Notice of Privacy Practices by calling the office and requesting a received copy be sent in the mail or asking for one at the time of my next |
|appointment. |
| |
| |
| |
|PRIVACY COMMUNICATION FORM |
| |
|In complying with health information privacy act, HIPPA, we want to make sure that we guard |
|your privacy according to your wishes when it comes to family, friends and co-workers. |
|* * * Please answer the following questions * * * |
| |
| |
|May we leave messages concerning your appointments/treatment with a co-worker, receptionist or secretary that regularly answers your calls? |
|[pic] |
|[pic] |
| |
|May we leave messages on a voicemail at work? |
|[pic] |
|[pic] |
| |
|May we leave messages on an answering machine at home? |
|[pic] |
|[pic] |
| |
|May we discuss your appointments/treatment with your spouse? |
|[pic] |
|[pic] |
| |
|If yes, what is their full name: |
| |
| |
| |
| |
| |
| |
| |
|Are there persons other than yourself (i. e children, friends, or other family members, etc.) that you wish to discuss your appointment / treatment with if requested? |
|[pic] |
|[pic] |
| |
|If yes, please list name and relationship below: |
| |
| |
| |
| |
| |
| |
| |
| |
|Name |
|Number |
|Relationship |
| |
|1. |
| |
| |
| |
| |
|2. |
| |
| |
| |
| |
| |
| |
| |
|You must inform us, in writing, of any changes in your directives. It will be kept in your file to help us know to whom we may relay your health information. Thank you.|
| |
| |
| |
| |
| |
| |
| |
| |
| |
|Signature of the Patient or Representative |
| |
|Date: |
| |
| |
| |
| |
| |
|Name of the Patient or Representative |
| |
|Description of the Representative’s Authority |
| |
|* |
| |
| |
| |
|CONTROLLED SUBSTANCE AGREEMENT |
| |
|The treatment of pain is a necessary and important part of caring for patients. We are committed to making sure we address your pain needs while providing you with |
|alternatives designed to minimize the addictive potential of the treatments we use. In this regard, we have a Pain Management program in cooperation with Pain Management|
|Consultants to insure you know about and have access to the best, safest treatments available. If your pain requires ongoing prescriptions for controlled substances with|
|significant addiction potential we will be asking you to see a specialist. Controlled substances are often addictive and must be taken exactly as prescribed. To clarify |
|our expectations in giving you this medication and to emphasize the risk of taking these substances we are asking you to read and sign this agreement |
|I, _______________________________, understand that if I am prescribed a controlled substance I must adhere to the following restrictions. Failure to conform to any of |
|the below listed restrictions may result in being dismissed as a patient and being reported to the police. |
| |
|I will not use alcohol/illegal drugs while being prescribed medication(s). |
|I will not take any other prescribed medications without first notifying my doctor. |
|I will notify my doctor immediately of any other physician(s) currently prescribing me a controlled substance(s) or that have been prescribed to me in the past thirty |
|days (including Emergency Rooms and Immediate Care Centers). Legally, failure to do so is a crime (Obtaining or Attempting to Obtain Drugs by Fraud and or Deceit) and |
|may be reported to the police. |
|I will submit to random urine and/or serum drug screens as ordered. |
|I will purchase all of my medication at _____________ pharmacy and authorize my doctor to communicate with my pharmacist. |
|I authorize my doctor to communicate with all physicians that I have seen. |
|I understand that it is illegal to share this medication. |
|I agree to keep my medication locked in order to prevent loss or theft. |
|I understand that 1 will be taken off this medication if there is evidence of addiction and/or abuse. |
|I understand that this medication may cause drowsiness and slower reflexes, interfering with the ability to drive and operate machinery, and short-term memory |
|impairment. |
|I agree to keep all scheduled appointments with my physician/therapist My medication may be weaned and discontinued I fail to attend my scheduled appointments. |
|I also understand that part of my treatment may involve reduction and discontinuation of any addictive medications. |
|I authorize this office to release a copy (or original) of this controlled substance agreement to the Police if I violate any of the listed terms or at their request. |
|Have you received any prescription medications from any other physician in the past thirty days? [pic][pic] |
|If yes, please list physician and medication on back. |
|I understand I may be called at any time to the office for a count of all my remaining medications. I agree to arrive on the day notified and will be responsible for any|
|costs this may incur. |
|I waive my right of privacy and authorize my doctor to contact any health care provider, legal authority, friend and/or relative in order to obtain or provide |
|information about my care (including abuse of controlled substances). |
|No refills will be authorized on weekends, Holidays, after office hours or by producing a police report Lost/stolen medications will not be replaced. |
| |
| |
| |
| |
| |
| |
|Signature of the Patient |
| |
|Date: |
| |
| |
| |
| |
| |
|Signature of the Physician |
| |
|Date: |
| |
|* |
| |
| |
|CONSENT FOR PROCEDURE / TREATMENT FORM |
|This form needs to be signed In order for Dr. Ashwani Srivastava, MD to treat you. |
|If no procedures are being done at this time please check the box provided. |
| |
| |
|[pic] |
|No procedures are being done at the time of signing |
| |
|[pic] |
|I authorize and direct Dr. Ashwani Srivastava, MD, and his assistants as necessary to perform quality care, to perform the following procedures(s) treatments(s) upon |
|me: |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|[pic] |
|The nature and purpose of the procedure, alternative methods of treatment, and potential risks and |
|complications listed below have been fully explained to me, including the following: |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
| |
|I acknowledge that the practice of medicine is not an exact science and that no guarantees have been made to me as to the outcome of the procedures and/or treatments. |
| |
|I grant this consent without duress, confusion, or pressure from any physician and/or his staff, associates, or colleagues. |
| |
| |
| |
| |
| |
| |
| |
|Patient Signature |
| |
|Date: |
| |
| |
| |
| |
| |
| |
| |
|Witness Signature |
| |
|Date: |
| |
| |
| |
| |
| |
| |
| |
|Informant’s Signature |
| |
|Date: |
| |
| |
| |
| |
| |
| |
| |
|Informant’s Relationship to Patient |
| |
| |
| |
| |
| |
|** |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- crm dynamic log in
- dynamic capabilities examples
- dynamic capabilities framework
- dynamic capabilities pdf
- dynamic capabilities theory
- dynamic capabilities model
- dynamic capabilities concept
- dynamic capabilities definition
- dynamic capability theory
- dynamic capability
- nike dynamic capabilities
- txwic crm9 dynamic main