Patient Information Form

Photo I.D and Insurance card(s) are required at every patient appointment to verify identity - per FTC guidelines

Thank you for choosing ENT Surgical Associates! ALL information is kept confidential. If the information you provide is not correct - we cannot process your claim through your insurance company. ALL copays are due at the time of service.

Patient Name:

Date of Birth:

Home Phone:

Cell Phone:

SSN:

Status:

Single Married Separated Divorced Widowed

Address:

City:

State:

Zip Code:

Email Address:

Patient Employer:

Work Phone:

Ext.

Employer Address:

City:

State:

Zip Code:

Nearest Relative:

Phone:

Emergency Contact:

Relation to Patient:

Phone:

Does the patient have an Advance Directive?

Yes No

Referring Physician or Primary Physician:

RESPONSIBLE PARTY INFORMATION (If it is NOT the patient)

Name of Responsible Party:

Relation to Patient:

Address:

(write same - if address is the same as patient)

City:

State:

Zip Code

Home Phone

Work Phone

Cell Phone

SSN:

Date of Birth:

Employer

Address:

City:

State:

Zip Code:

PRIMARY INSURANCE INFORMATION

Name of Insured:

Relation to patient:

SSN:

Date of Birth:

Employer:

Address:

City:

State:

Zip Code:

Insurance Company:

Policy #:

Group #:

Copay Amount:

Effective Date of Policy

Expiration Date of Policy:

Does the patient have a Secondary Insurance to be filed?

Yes No

SECONDARY INSURANCE INFORMATION (ONLY IF APPLICABLE FOR PATIENT)

Name of Insured:

Relation to Patient:

SSN:

Date of Birth:

Employer:

Address:

City:

State:

Zip Code:

Insurance Company:

Policy #:

Group #:

Copay Amount:

Effective Date of Policy:

Expiration Date of Policy:

I authorize release of any information concerning my (or my dependent's) health care, advise and treatment providing for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits payable to the insured party to be directly paid to ENT Surgical Associates of Central Georgia, PC and/or ENT Surgical Center of Central Georgia, Inc. I understand that I am financially responsible for any charges not covered by my insurance, and they are due in full upon receipt of notice. ALL information use for any purpose will be within the guidelines stated in our patient privacy policy according to HIPAA Law.

ENT Surgical Associates and ENT Surgical Center are separate facilities and are billed separately. ALL Claims are filed to the insurance company as a courtesy to our patient - but if the claim is denied the patient or the responsible party will be held responsible for payment(s). Any out-of-network claims for the ASC that have been paid to the insured party must be remitted immediately or the patient/insured party will be responsible for the account in full upon receipt. signing below states you verify all information to be complete and accurate and understand our policy for insurance processing and payment(s) to our practices. The Insurance company is responsible for the patient's policy and it is a contract between the Policy holder and the Insurance Company.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient (or Parent/Guardian if patient is a minor)

Date:

PLEASE TAKE AN ADDITIONAL MINUTE TO TELL US HOW YOU HEARD ABOUT OUR OFFICE...

If Friend is chosen, please list your friend's name here:

If Internet is chosen, please list the website:

If Referral from Dr. is chosen, please list the name of doctor here:

If Other is chosen, please specify:

INSURANCE CARD AND PICTURE I.D. ALSO REQUIRED - WE CANNOT FILE A CLAIM TO THE INSURANCE WITHOUT THE INSURANCE CARD. THANK YOU.

FORM MUST BE COMPLETED AND SIGNED OR INSURANCE CANNOT BE PROCESSED. PAYMENT(S) REQUIRED IN FULL BEFORE APPOINTMENT WITH PROVIDER.

ENT SURGICAL HEALTH HISTORY FORM

First Name:

Middle:

Last:

Date of Birth:

Home Phone:

Cell Phone:

Gender

Male Female Other

Review of Symptoms - Check only the ones you NOW have or have had RECENTLY, if there are no symptoms check NONE

MEDICATIONS: List all medication you are currently taking. Include ALL medication even over the counter ones.

Drug Name:

Dosage:

Frequency:

Status:

Current Chronic Discontinued

Add more

List ALL Allergies:

Allergic Reaction

Add more

PAST MEDICAL HISTORY - Please provide a complete history including all illnesses, injuries, hospitalizations, and operations

List ALL Illnesses, Injuries & Operations:

Date:

Hospital:

Treatment:

Physician:

Response:

Add more

Has the Patient Listed Tested Positive for any of the following:

HIV

Yes No

Hepatitis (If positive please list type)

Yes No

Type of Hepatitis:

Other Communicable Disease:

Yes No

Last Chest X-Ray

Normal Abnormal

Date of Last Chest X-Ray:

Last TB Skin Test

Normal Abnormal

Date of Last TB Skin Test:

Last EKG

Last Eye Exam:

FAMILY HISTORY - Please list all Blood Relatives with their current health status and any illnessess that they have, had or have:

List of Blood Relatives:

Health Status:

Age if Living:

Cause of Death:

Illnesses:

Age of Death:

Add more

Alcohol

Never

Beer(s)

Liquor

Wine

Beer Per Week:

Liquor Per Week:

Wine Per Week:

How Many Years?

Smoking

Never Current Previous

Packs Per Day:

How many Years?

Caffeine

None Current Previous

Cups per Day:

How many Years:

Others:

Aspirin

None Current Previous

Quantity per Day:

How many Years:

Others:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

ALL INFORMATION IS REQUIRED TO BE COMPLETE AND ACCURATE, INSURANCE COMPANIES REQUEST THIS INFORMATION TO VERIFY CLAIMS THAT ARE PROCESSED, THIS FORM WILL BE UPDATED ANNUALLY

Your information will be encrypted.