New Patient Forms

PATIENT INFORMATION

Account #

Language Spoken at home

First Name

Middle Initial

Last Name

Age

Date of Birth

Social Security #

Address

Apt / Unit

City

State

Zip

Phone ph

Work

Cell

Email address

Do we have your permission to email you regarding results/appointment reminders?

Yes No

Employed by

Occupation

Pharmacy Name

Phone

**SPOUSE (or partner) INFORMATION**

First Name

Middle Initial

Last Name

Date of Birth

Social Security #

Employer

Occupation

Cell No.

Spouse Email

Referred by

Primary Care Physician

Phone

INSURANCE INFORMATION

Policyholder

Insurance Company

Group

Provider Phone # OR Customer Service #

Secondary Insurance

Group #

I have verified that the provider is in network and I take responsibility for any unpaid charges.

I hereby authorize PRAFULLA K KONERU, M.D., S.C. to release to my insurance company or its representative, any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such Medical or Surgical Care. I also authorize my insurance company to pay directly to the above named practice the amount due in any pending claim for Basic Medical, Major Medical and/or surgical treatment or services, by reason of such treatment or services rendered to me.

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

Signature

Date

Routine HPV Testing Consent Form

Recent medical advances have shown most cervical cancer is caused by HPV (Human Papilloma Virus).
The PAP smear has always tested for cervical cancer, but it is not perfect and can miss the disease up to 50% of the time.
Testing for HPV virus has a higher sensitivity in determining the risk for cervical cancer.
HPV testing is recommended by many health organizations including the American Cancer Society (ACS), National Institute for Health (NIH) and the American College of Obstetricians and Gynecologists (ACOG.) Our office now recommends this testing procedure as well.
HPV testing should be done on women between the ages of 30-64 years of age along with their annual PAP smear (called co-testing).
HPV is a very common virus, almost like a cold. Any woman that has had ANY sexual contact (not just intercourse) may acquire the virus

Many women get HPV but the immune system will suppress the virus
If you test positive for HPV, your body is not able to fight off the virus
If you test positive for HPV, your doctor will need to follow you more closely.

Insurance Company payments:

Most insurance companies will pay for the HPV testing, however; our office cannot guarantee payment of any type.
You should contact your insurance company for verification; the CPT (procedure) code is 87624.
If you have not met your deductible or your co-insurance amount, you will be responsible to pay for the testing.

We will perform this test on everyone between the ages of 30-64, unless you specifically request not to be tested with the most sensitive tests available for cervical cancer.
If your pap smear shows an abnormal result called “Atypical Squamous Cell of undetermined Significance, the lab will automatically do the HPV testing to determine whether you are at high risk and require additional office procedures called colposcopy & biopsy.

YES, I want HPV testing done. NO, I don not want HPV testing done

Signature

Date

It is the policy of our office to call you with Abnormal Laboratory Results, Pap Smears, Ultrasound and X-ray Reports. If you have not heard from us in 21 days of having the testing completed, please call our office.

Whom may we notify of abnormal test results?

Patient Only Spouse Other

Other, Please specify

DO WE HAVE PERMISSION TO LEAVE DETAILED MESSAGES ON YOUR VOICEMAIL?

Yes No

BEST NUMBER TO LEAVE MESSAGES

PLEASE NOTIFY OUR OFFICE OF ANY CHANGES IN THE ABOVE

Advance Directive

Patient Signature

Office Policy Effective 4/1/17

There will be a $25 charge for any No-Call No-Show appointments or late cancellation. Please be sure to give a 24hrs notice if you’re unable to make your appointment

Emergency Contact

Name

Relationship

Number

Referred by

PERSONAL HISTORY

Name

Date of Birth

Religion

Education

GYNECOLOGICAL & OBTETRICAL HISTORY

Date of last menstrual period

Was it normal?

Yes No

What birth control are you using now?

None

IUD

DIAPHRAGM

TUBAL LIGATION

OTHER

Age first period began

# of day between

Days of menstrual flow

# of pads/tampons per day used at the beginning of period

End

Are you periods irregular?

Yes No

Pain with or prior to periods?

Yes No

Clots with Periods?

Yes No

Any bleeding between periods?

Yes No

Any bleeding during or after sex?

Yes No

Any bleeding during or after sex?

Yes No

Any pain with sex?

Yes No

Medication for pain with periods?

Yes No

Any abnormal vaginal discharge?

Yes No

Have you ever had a venereal disease

Yes No

Have you had the German Measles?

Yes No

Have you ever had a pelvic infection?

Yes No

Have you passed the “change of life?”

Yes No

If yes, Please describe

Have you had any bleeding?

Yes No

Any hot flashes?

Yes No

Any hot flashes?

Yes No

Have you noticed any lumps or discharge from your breasts or nipples?

Yes No

Do you lose urine when you cough or sneeze?

Yes No

How many total Pregnancies?

How many living children?

How many miscarriages or abortions?

Any premature babies?

Date of last pap smear

PREGNANCIES: (list in order)

Additional Dates

Age at first sexual intercourse

ALLERGIES & SENSITIVITIES: (Allergic to)

A. Morphine, Codeine, Demerol

Yes No

If yes, Please explain

B. Morphine, Codeine, Demerol

Yes No

If yes, Please explain

C. Aspirin or other pain medication

Yes No

If yes, Please explain

D. Tetanus or other serum

Yes No

If yes, Please explain

E. Adhesive tape, Iodine, Foods

Yes No

If yes, Please explain

F. Penicillin, Tetracycline

Yes No

If yes, Please explain

G. Sulfa Drugs, other Antibiotics

Yes No

If yes, Please explain

H. Any other Drug or Medication

Yes No

If yes, Please explain

DRUGS RECENTLY TAKEN

Within the past 6 months have you taken any of the following? If so, when and what amount, if known

A. Cortisone, ACTH

Yes No

If yes, Please explain

B. Anticoagulants (Blood thinners)

Yes No

If yes, Please explain

C. Anticoagulants (Blood thinners

Yes No

If yes, Please explain

D. Hypertensive’s (high Blood Pressure Medicine

Yes No

If yes, Please explain

E. Any other drugs

Yes No

If yes, Please explain

PAST HISTORY

MEDICAL HISTORY

High Blood Pressure, Asthma, Hepatitis, etc.

Hospitalizations?

Serious Injuries?

Transfusions?

When?

SKIN

Have prolonged bleeding from cuts?

Ever had blood clots in legs?

EYES

Wear glasses or contact lenses

EARS

Difficulty in hearings?

Ringing in ears?

Frequent Dizzy Spells?

URINARY TRACT

Ever had a kidney or bladder infections

Now have pain, urgency or burning with urination?

Ever passed blood in urine?

NEUROMUSCULAR

Ever had a convulsion?

Ever has swollen red or still joints?

Have paralysis or deformity?

ENDOCRINE

Any thyroid trouble?

Ever been told you’re diabetic?

Has your weight varied over 10 lbs in the past year?

FAMILY HISTORY

Cancer

Diabetes

Heart disease

Hypertension

Other

SOCIAL HISTORY

Marital Status

If married, How long?

If divorced, how long?

If married, is your marriage satisfactory?

Yes No

Do you drink?

Yes No

How much?

Are you usually depressed lately?

Yes No

Any special problems worrying you?

Yes No

Are you presently taking recreational drugs, marijuana, Do you smoke? cocaine, etc

Yes No

If so, what?

Do you smoke?

Yes No

How much?

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

Name / Signature of person completing this form

Relationship to patient

Date

Informed Voluntary Consent for HIV Test

I have voluntarily agreed to take a blood test in order to determine whether I have been infected with the human immunodeficiency virus (HIV) or any other identified causative agent of acquired immunodeficiency syndrome (AIDS.)

EXPLANATION OF THE TEST

I understand the test is performed by withdrawing a sample of my blood and conducting laboratory tests and that the purposes of the test are to determine whether I have been infected with HIV and to help my physician decide what kind of medical treatment I need. Further, if my test results are positive, the result will be reported to the Illinois Department of Public Health. I know to take steps to protect other persons from my infections, and I will be able to make decisions about my future health care and other personal matters.

I understand that an HIV test results may not be clear. I understand that a positive test result means that I probably have HIV infection and that I should consider myself able to infect other people. However, very rarely, the test can be wrong and make it appear that I am infected when I am not. I understand that if the test results are positive I will provide referrals for further information of counseling for follow up care and for precautions against transmitting the infection. I also understand that being HIV positive does not mean that I have AIDS. I understand that my doctor must look at a number of factors to determine if I have AIDS and that there is no single 100% accurate test that can show if I have AIDS.

I understand that a “negative” test result means that I probably do not have an HIV infection. However, I understand that if I have been recently infected with the HIV virus it may take an indeterminate period of time before my blood becomes HIV positive and during that time I can infect other people. Therefore, if my test results are negative I may need to be testes in the future to confirm that I have not been infected.

EXPLANATION OF PROCEDURES TO BE FOLLOWED

I understand that all reasonable efforts to provide confidentially to the extent provided by law will be made and the results will not be disclosed to unauthorized third parties without my express written authorization. I understand my physician or health care facility where the test was done can disclose my identity and the results of the test to certain legally authorized persons or entities, such as an authorized agent or employee who provided patient care or handles or processes specimens of body fluid or tissue and who has a need to know such information.

I understand that upon my request and when permitted by law I have the right to provide written informed consent by using a coded system that does not link my identity with the consent to be tested or the result of the test. I further understand that I have the right to withdraw my consent to the testing process at any time.

I specially request that the result of this test by communicated to the following physicians, other health care providers and health facilities involved in my medical care.

With the information provided above being clear to me and having been afforded the opportunity to have asked questions and have all of my questions answered. I hereby warrant that I freely give my informed consent to test my blood for HIV infection

Signature of test subject or legally authorized

Physician’s signature

Physician’s Date

Prafulla Koneru, M.D. Financial Agreement and Consent 2017

Your Signature at the end of this document will indicate that you have read, understand and agree to the policies outlined below.

Update your Contact Information: We depend on accurate information to contact you regarding prescriptions, lab results and billing. If you move or change your e-mail or telephone number please inform the front desk so we can update our database.

Billing your Insurance

Please present your current health insurance card at each office visit. If you present an incorrect card, please contact us immediately to update your information.
If you have no insurance then payment in full is required at the time of service.
Our office will bill validated primary and secondary insurance. If you have a secondary, please clearly indicate which insurance is primary and which is secondary. Any remaining balance will be billed to you.
Know your insurance. If you have a deductible or coinsurance you will likely have a balance for which you are responsible. If your insurance plan has exclusions, you will owe a balance. Please check with your insurance company to determine your benefits and the portion you may owe.

Payment for Service

Co-pays, co-insurances and deductibles must be paid at the time of service. If your co-pay is not made within 24hours of the time of service, there will be an additional $15.00 fee.

Initial

We require a valid credit card be kept on file to cover any past due balance. Please see back of this sheet.
We accept cash, checks, money orders, Visa, MasterCard and debit cards. Credit cards and debit cards payments may be made in person or by phone.

Returned Checks: The charge for a non-sufficient funds (NSF) check is $25. You must pay in full for the NSF check and NSF fee within 10 days of notice. If payment is not received by the due date, we will forward the returned check to the District Attorney’s office. It is a felony to knowingly write a bad check. For the next 36 months, cash or equivalent payment at the time of service is required.

Collections/past Due Accounts: When your account remains unpaid after 90 days we maintain the right to refer the account to an outside collection agency. If your account is sent to a collection agency you may be asked to find another provider.

No Shows and Cancellations: Please be considerate.

We require a 24-hour notice to cancel or reschedule an appointment. For appointments scheduled within 24hours of the appointment time, a 2 hour notice is required. Failure to give proper notice for cancellation or reschedule will results in:

A $25 charge for missed appointments or late cancellations.
Potential dismissal from our practice for a third missed appointment.

Copies of Medical Records and Other Forms: Records requests are generally fulfilled within 5 days. When the request is addressed at the time of service, we can generally provide the records immediately. There is a copy fee for medical records. If you would like us to fax the records to another healthcare provider, there is no charge for this service.

I acknowledge and understand the office policies and procedures explained above and have received a copy. I hereby authorize my insurance company to pay Prafulla K. Koneru, M.D. directly. A copy of this authorization can be considered an original for insurance purposes.

I hereby consent to and authorize the performance of all examinations, treatments and medical services by Prafulla K. Koneru, M.D. and her staff, which may be deemed advisable. My signature on this document indicates that I have read, understand and agree to the policies outlines in this document.

Signature of Patient or Parent Guardian (if patient is under 18)

Date

Prafulla Koneru, M.D. Credit Card on File Policy

Your Signature at the end of this document will indicate that you have read, understand and agree to the policies outlined below.

As of May 2017, we require a valid credit card be kept on file

This policy is designed to

Help you avoid all billing related fees and hassles.
Streamline the billing process in our office and eliminate the expenses related to handling overdue accounts.

Your signature will authorize the card to be sued only when your balance becomes past due.

How the policy works:

At the time of registration or check-in, you will be asked for your credit card information. That information will be held securely and will only be used if you have a past due balance.
As always, we will bill your insurance carrier first for all charges related to the visit. If you have secondary insurance, you must provide both primary and secondary insurance information at the time of the visit and clearly indicate which is primary.
When we receive an explanation of benefits (EOB) from your insurance we will send you a statement to the address you provide. If we have not received payment by the end of that same month, we will charge the credit card on file for the balance due (on that statement).
You are responsible to update our office if your address changes. If your mail is returned, your credit card will be billed on the date on the statement we mailed.
If we attempt to use your card and it is declined or has expired, we will contact you by telephone, and you will be responsible for updating our records.
If your balance exceeds $100, we will contact you first to set up a payment plan; however, if we are unable to reach you within 3 business days and/or you do not respond to your messages, we will automatically set you up for a $100 per month payment plan until your balance is paid in full. Your card will automatically be run each month.

Again, your credit card will only be charged when your balance becomes past due

Please remember that this policy does not restrict your right to appeal any charge made to your credit card. Should you feel that we have charged your card in error, please contact our office so we may correct any errors or resolve any concerns. If a mistake had been made, we will reverse the charges. In the event of duplicate payments, we will issue a refund. We will make every effort to resolve any billing issues with your insurance company before you are billed or charged. This credit card policy is not intended to reduce or eliminate your ability to appel unpaid claims with your insurance company but rather to quickly and effectively handle past due balances after every effort has been made to receive payment from your insurance company.

I have reviewed a copy of Prafulla Koneru, M.D.’s billing policy and agree to provide my credit card information for the sole purpose of payment for medical care provided.

Signature of Authorized User

Date

Name as it appears on your Credit Card

Credit Card Number

Visa or MasterCard Only

Expiration Date

CVV Code

If you do not agree please read the statement below and initial.

I will pay FULL balance once I receive statement

Initial

NOTICE OF PRIVACY PRACTICES

PATIENT ACKNOWLEDGEMENT FORM

Your privacy, including the confidentiality of your health information, is very important to us. Additionally, Federal Law prohibits the unauthorized release of certain medical and health information. Before our office can use your Protected Health Information for treatment, payment and health care operations, you must acknowledge that you have received a copy of our Notice of Privacy Practices informing you how our office may use and disclose your Protect Health Information.

You should carefully read out Notice of Privacy to understand how we take steps to protect the privacy and confidentiality of your Protected Health Information. Federal Law gives you certain rights regarding the use and disclosure of your Protected Health Information. Their rights include:

The right to request that we restrict how your Protected Health Information can be used or disclosed for treatment, payment or health care operations.
The right to receive confidential communications of your Protected Health Information, if applicable
The right to inspect and copy your Protected Health Information
The right to receive an accounting of the disclosures of your Protected Health Information.

By signing this form, you acknowledge that you have received a copy of our Notice of Privacy Practices concerning the use and disclosure of your Protected Health Information.

Name / Signature

Date

Your information will be encrypted.