PATIENT INFORMATION FORM

PATIENT INFORMATION

If not applicable, type "none" into the field.

EMERGENCY CONTACT (non-family member, outside of your home)

SPOUSE / GUARDIAN

(Please, complete if patient is NOT the POLICY HOLDER for primary or secondary insurances):

INSURANCE INFORMATION

Meaningful-Use Data

Please Select the Corresponding Data

5. PREFERRED PHARMACY

Add Local Pharmacy

Patient Consent and Acknowledgment of Receipt of Privacy Notice

I understand that as part of the provision of health care services, Texas Thyroid & Endocrine Center, P.A. creates and maintains health records and other information describing among other things, my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment.

I have been provided with a notice of privacy practices that provides a complete description of the uses and disclosures of certain health information and identifiers such as my name, date of birth, insurance card and driver's license, telephone number and address. It also explains how I may amend my medical records, obtain a record of disclosure or file a complaint regarding disclosure of my records. I understand that I have had the right to review the notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations(quality assessment and improvement activities, underwriting, premium rating conducting or arranging for medical review, legal services and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested.

By signing this form, I consent to the use and disclosure of protected health information about me for the purposes of treatment, payment and health care operations this includes calling me for and appointment reminder. I have the right to revoke this consent, in writing, except where disclosures have been made in reliance on my prior consent.

THIS CONSENT IS GIVEN FREELY WITH THE UNDERSTANDING THAT:

1. Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed for reasons outside of treatment, payment or health care operations with out my prior written authorization, except as otherwise provided by law.
2. A photocopy or fax of this consent is as valid as the original.
3. I have the right to request that the use of my Protected Health Information, which is used or disclosed for the purpose of treatment, payment or health operations be restricted. I also understand that Texas Thyroid & Endocrine Center, P.A. And I must:

• agree to any restriction in writing that I request on the use and disclosure of my protected health information and,
• agree to terminate any restriction in writing on the use and disclosure of my Protected Health Information which have be previously agreed upon.

CONDITIONS OF TREATMENT

1. Insurance Verification and/or Pre-Authorization

Many insurance companies require pre-authorization for various procedures. Texas Thyroid & Endocrine Center, P.A. will assist the patient in obtaining the necessary pre-authorizations when needed, but it is ultimately the patient's responsibility to determine if your insurance company requires this. Failure to obtain necessary pre-authorization or second opinions may result in a reduction or rejection of benefits by the insurance company.

2. Assignment of Insurance Benefits

The undersigned hereby authorizes the release of any medical or other information necessary to process all claims. I also request payment of government and medical benefits to TEXAS THYROID & ENDOCRINE CENTER, P.A. for services rendered to myself or to my minor child or for those whom I have guardianship or Power of Attorney for. I understand that I am financially responsible for charges that are not covered by my insurance company including late penalty charges. I agree that a photocopy of this authorization is as effective as the original.

3. Confidentiality

Confidential information expressly identifies the medical nature of the service rendered to a patient, and includes all information and records obtained in the course of treatment. It includes information from history and physician examination, diagnosis, treatment rendered, laboratory and radiology results, progress notes, and miscellaneous medical reports.

4. Medicare authorization: Patient's certification authorization to release information and payment request

5. Authorization for disclosure of Information for Purpose of Service Reimbursement

I hereby authorize Texas Thyroid & Endocrine Center, P.A. to disclose all or part of the medical record of the above patient to any company that may be responsible for payment of all or part of that patient's medical charges. Disclosure of the medical record may be necessary to determine eligibility for benefits and to obtain reimbursement for health care services. I hereby release Texas Thyroid & Endocrine Center, P.A. from all legal responsibility or liability that may arise from disclosure of these records. I understand that I may revoke this authorization at any time in writing.

6. Financial Agreement

I understand that in consideration of the services rendered, I am obligated to pay Texas Thyroid & Endocrine Center, P.A. in accordance with its regular rates, terms, or contractual agreements. I understand that I am responsible for any service "not covered" by insurance and that the obligation to pay for medical services may not be deferred for any reason. If the account is referred to any agency for collection, I agree to pay all collection expenses.

7. I have read and understand this financial agreement. I have had an opportunity to ask questions and, at my request, receive a copy of my signed form. I accept the responsibility of its terms.

OFFICE POLICIES

CANCELLATION POLICY

A minimum of 24 hours cancellation notice is required for all scheduled medical office appointments. It is the patient's responsibility to remember scheduled appointments. As a courtesy, our office staff will do our best to provide a reminder call 1-2 days prior to the scheduled visit.

All missed appointments and cancellations in less than 24 hours from the day of the appointment or if a patient has rescheduled 3 consecutive appointments, a charge of $50.00 will apply. A missed appointment for a procedure will be charged $100.00.

COPAYMENT, COINSURANCE, DEDUCTIBLES

All anticipated patient payments related to deductibles and co-insurance are due at the time of the visit. Please have your co-payment ready at the time of check-in. Any account past due more than 60 days may be assessed an interest charge per month on the unpaid balance and a $30.00 billing fee.

If my account is referred to a collection agency, or credit-reporting agency, or a lawyer, I agree to pay all associated costs incurred. Any amounts due from me cannot be discharged in bankruptcy and are binding on me, my assigns, heirs, executors, or estate.

REFERRALS

For established patients with HMO insurance, it is the patient's responsibility to have a valid referral, if necessary, at the time of visit. As a courtesy to our patients, our staff requests referral renewals when necessary from the patient's primary care physician. It is, however, ultimately the patient's responsibility to make sure all referrals are current and valid. Failure to provide a referral will result in either full payment from the patient or a reschedule of appointment, which is subject to the late cancellation fee of $50.00, if rescheduling to occur in less than 24 hours prior to scheduled appointment.

PRESCRIPTIONS

If you require change in pharmacy or PRESCRIPTIONS AUTHORIZATION 30 days or more after the last date of service, there will be a charge of $15.00.

I have read, understood and agree with all of the above, and accept the responsibility of its terms. I was given a copy of the above policies.

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.

PERSONAL & FAMILY HISTORY

ALLERGIES (Please include type of reaction to each allergy listed)

PERSONAL MEDICAL HISTORY

List ages and birth weights:

Female:

HOSPITALIZATIONS / SURGERIES (Please include date(s))

MEDICATIONS (Both prescription and over-the-counter including herbal, vitamins, etc)

FAMILY HISTORY (List any health problems of your mother, father, siblings, children or grandparents)

SOCIAL HISTORY (Please write in or select the information that applies to you)