ADVANCE DIRECTIVES
I hereby assign my insurance benefits to be paid directly to the physician for services rendered. I understand that I am financially responsible for any non-covered services, co-insurances, or deductibles, including any balance of my account until the insurance pays their portion. If my insurance pays me directly for services provided by the physician, I agree to forward such payments to Paseo Medical Specialists, dba Arizona Premier Pulmonary & Sleep Specialists. I understand that it is my responsibility to notify this office of any changes in the above information. I also authorize the physician to release any information required to process this claim. In the event that any unpaid balance should be forwarded to a collection agency, I understand that I will be fully responsible for any and all costs. I also understand that my protected health information (PHI) will not be released in any form without my written consent, as described in this office’s privacy and confidentiality policy. I understand that I have a right to a copy of this policy at any time, and that any requests for access to or copies of my PHI must be made in writing. I also understand that it is the policy of this office to give at least 72 hours notice prior to receiving requested PHI information, and that I may be charged a nominal copying fee for any records requested for my personal use. I also understand that any previous account balances must be paid in full prior to the release of any records, to any entity, myself included. Charges for minors will be the responsibility of the signer below.
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.
acknowledge and agree that I have received a copy of Paseo Medical Specialists, dba Arizona Premier Pulmonary & Sleep Specialists Notice of Privacy Practices.
Paseo Medical Specialists, dba Arizona Premier Pulmonary & Sleep Specialists, made the following good faith efforts to obtain the above-referenced individual's written acknowledgement of receipt of the Notice of Privacy Practices:
(Identify the efforts that were made to obtain the individual's written acknowledgement, including the reasons (if known) why the written acknowledgement was not obtained)
Our goal is to provide quality medical care in a timely manner. In order to do so we have had to implement an appointment/cancellation policy. The policy enables us to better utilize available appointments for our patients in need of medical care.
Scheduled AppointmentsFor a scheduled appointment please call 602-978-6100 Ext 125
In order to be respectful of the medical needs of the community please be courteous and call our office promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in urgent need of treatment.
If it is necessary to cancel your scheduled appointment we require that you call 24 HOURS in advance. Appointments are in demand, and your early cancellation will give another person the possibility to have access to timely medical care.
To cancel appointments please call 602-978-6100 Ext. 126
Late cancellations will be considered as a “no show”.
A “no show” is someone who misses an appointment without canceling it 24 HOURS in advance. No-shows inconvenience those individuals who need access to medical care in a timely manner.
A failure to present at the time of a scheduled appointment will be recorded in the patients’ chart as a “no show”. An administrative fee of $40.00 will be billed to the patient’s account. The patient will be sent a letter alerting them to the fact that they have failed to show up for an appointment and did not cancel the appointment 24 HOURS in advance. A copy of the letter will be placed in the patient file. Three “no shows” will result in the temporary suspension of services. In order to reinstate services the patient will be required to meet with the practice administrator or delegate to evaluate the situation.
Life-threatening Emergencies
Always call 911 immediately in case of a life-threatening emergency.
For the purpose of continuity of care, I hereby authorize information about my medical condition (including treatment options, prescriptions, diagnostic tests, etc.) to be discussed with the following individual(s):
Add Additional Name
I understand that this authorization may be changed or revoked at any time by giving written request to Paseo Medical Specialists, dba Arizona Premier Pulmonary & Sleep Specialists, and until such time, shall remain valid indefinitely. I also understand that I may request information to be discussed on a limited basis, such as:
(Describe any limitations that you do not wish to be disclosed with the individual(s) listed above):
We are delighted to schedule and provide the very best care and service at Arizona Premier Pulmonary And Sleep specialists. Please take time to answer the following questions.
Information contained here is a confidential record NOT to release without your authorization.
Names of Specialists that you see:
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Add Additional Medication
Add Additional Allergies
PLEASE DESCRIBE IF APPLICABLE TO YOU
How long is cough going on?
For how long?
Describe your shortness of Breath: Mark One Option Only
How long ago:
Duration
Review Of Symptoms: (Please Check POSITIVE SYMPTOMS BELOW)
RESPIRATORY
Add Additional Surgery & Procedures
PRIOR SLEEP DISORDER DIAGNOSIS OR STUDIES
Any weight change during the past year:
How likely are you to doze off or fall asleep in the following situations in contrast to feeling just tired?
(0 = would never doze, 1 = slight chance of dozing, 2 = moderate chance, 3 = high chance of dozing)
SITUATION
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