Patient Registration Form

How did you hear about Texas Ear and Vestibular Institute?

Provider Referral

Friend

Other

If Other, please specify:

Today's Date:

Patient Information

Name:

Last Name:

First Name:

Middle Initial:

Date of Birth:

Age:

Sex:

Height

Weight

Marital Status:

Married Single Widowed Divorced

Address:

City:

State:

Zip:

Email:

Social Security Number:

Home No.:

Business No.:

Cell No.:

Primary Care Physician:

Primary Care Physician No.:

Referring Physician:

Referring Physician No.:

INSURANCE INFORMATION

Primary Medical Insurance

Primary Insurance Company:

Policy Holder:

Policy Holder DOB:

Relationship:

Policy No.:

Group No.:

Secondary Medical Insurance

Secondary Insurance Company:

Policy Holder:

Policy Holder DOB:

Relationship:

Policy No.:

Group No.:

GUARANTOR OR RESPONSIBLE PARTY (IF NOT INSURED)

Same as patient information (If different, please complete section below)

Name:

Date of Birth:

Relationship:

Address:

City:

State:

Zip:

Please select which phone number should we primarily call to:

Home Phone Number Business Phone Number Cell Phone Number

Home Number:

Business Number:

Cell Number:

Employer:

Employer No.:

Employer Address:

City:

State:

Zip:

EMERGENCY NOTIFICATION

Contact Person:

Relationship to Patient:

Home No.:

Work No.:

PREFERRED PHARMACY

Name of Pharmacy:

Phone Number:

Address:

City:

State:

Zip:

RELEASE OF HEALTH INFORMATION

Select one:

Texas Ear and Vestibular Institute MAY NOT discuss my healthcare and may not discuss and/or make financial arrangements with anyone, except as permitted by HIPAA and other applicable laws Texas Ear and Vestibular Institute MAY discuss my healthcare and MAY discuss and/or make financial arrangements with only the following individual immediate family members listed below:

Name:

Relationship:

Phone:

Add more

I understand that if I would like to authorize Texas Ear and Vestibular Institute to disclose my healthcare and/or financial arrangements with anyone other than the individuals listed above, I will need to execute an authorization that meets the requirements of the HIPAA Privacy Standards.

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.

Patient Name:

Signature:

Date:

Please provide a date or event, if any, upon which this Authorization will expire. Please mark only one selection.

No Expiration

Date of Expiration

If selected, please provide Date of Expiration:

Event:

If selected, please describe event upon which this authorization will expire:

PATIENT CONTACT PREFERENCES

I prefer to be contacted in the following manner:

Phone

If selected, please provide phone number:

Select one:

OK to leave message with detailed information OK to leave message with contact number only DO NOT LEAVE MESSAGE

Briefly describe what brings you in for an appointment:

If Cancer is selected, please list type:

Please list any medical problems you have that are not represented above:

Add more

Please list surgeries you have had, along with year if known:

Name of Surgery:

Year of Surgery:

Add another list of surgery

Please list all medications that you take, along with dose (you may provide a separate list if you have one):

Dosage:

Add another medication

Are you allergic to any medications?

Yes No

If allergic to medications, list them here:

Do you smoke or use nicotine products?

Yes No

If yes, please list type and how often:

Do you drink alcohol?

Yes No

If yes, please list how often:

Do you drink caffeine?

Yes No

If yes, please list how much:

Did you have a flu shot during the most recent flu season?

Yes No

What is your occupation?

Please select:

Full-Time Part-Time Self-Employed Student Retired

Patients 65 years old and over ONLY

Do you have a living will?

Yes No

Do you have a Do Not Resuscitate (DNR)?

Yes No

ASSIGNMENT OF BENEFITS

I hereby assign, transfer, and set over to Texas Ear and Vestibular Institute all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. All deductibles and co-pays are due at the time services are rendered and will be collected based on the information provided by your insurance company. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the above-named health care provider to release all medical information necessary to process my claims. This authorization will remain valid until I revoke it by written notice.

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 of Patient/Guarantor/Legal Guardian:

Date:

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Texas Ear and Vestibular Institute to (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used in processing insurance claims for the period of a lifetime. This order will remain in effect until revoked by me in writing.

I have requested medical services from Texas Ear and Vestibular Institute. On behalf of myself and/or my dependents, and understand that my making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

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 of Patient/Guarantor/Legal Guardian:

Date:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By my signature below, I acknowledge that I have received a copy of the Notice of Privacy Practices and understand my rights as a patient of Texas Ear and Vestibular Institute.

With my consent, Texas Ear and Vestibular Institute may use and disclose of my protected health information protected under Health Insurance Portability and Accountability Act of 1996 for treatment, billing/payment, and health care operations.

I understand that I have the right to request, now and in the future, how protected health information is used or disclosed to carry out treatment, payment, and health care operations. I understand that while Texas Ear and Vestibular Institute is not required to agree to my requested restrictions, if does agree, it is bound by that agreement.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the Practice’s Privacy Officer. I understand Texas Ear and Vestibular Institute may refuse me further service if I revoke the consent.

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 of Patient/Guarantor/Legal Guardian:

Date:

TEVI POLICES AND CONSENT TO TREAT

Initials:

Financial Responsibility Agreement:

I understand that charges not covered by my insurance company or my secondary insurance if applicable, as well as any applicable co-payments, coinsurance, and deductibles are my responsibility. All professional services rendered are charged to the patient and are due at the time of service, unless other arrangements have been made in advance by either the patient or his/her health insurance carrier. If your insurance company has not paid your account in 90 days, the balance may be transferred to you for payment.

If your insurance is with an HMO or other managed care program, Texas Ear and Vestibular Institute will bill them only if you present an appropriate authorization form from them. You may still be responsible for any deductibles, co-payments, or non-covered services. If you do not have an appropriate authorization each visit and/or treatment, the responsibility for the payment will be yours.

For companies with whom our physicians do not participate, payment for the first visit for the services is your responsibility. Texas Ear and Vestibular Institute will bill to your insurance carrier after second visit.

I understand that if I default on payment for services, that my account my be transferred to an independent collection agency, designated as credit risk and payment for services will be required at the time of registration for all future visits. I have read the financial policy as above. I understand and agree to above financial policy.

We currently accept cash, Visa, Mastercard, and American Express. Unfortunately, we are not accepting checks at this time. If you have any questions regarding your bill, please contact our billing office, CureMD, at 347-732-1357.

Initials:

Missed Appointments:

Your appointment time is set aside especially for you. Resources are assigned for each individual patient. We ask that for the courtesy to the Doctor and to other patients that you keep your scheduled appointments.

If you must change or miss an appointment, we require a 24-hour notice. Failure to provide a 24- hour notice to cancel your scheduled appointment will result in a “no show” fee of $50.00. A noshow fee must be paid prior to being seen at your next visit. Please note that insurance companies do not pay for no-show fees and therefore will not be billed for that charge.

Initials:

Consent of Treatment:

I authorize the staff at Texas Ear and Vestibular Institute to provide any diagnostic tests and examination indicated for treatment.

Initials:

Medication Policy Consent:

I authorize Texas Ear and Vestibular Institute to obtain a medication history and/or list of current medications via my pharmacy for medical records.

Initials:

Disability or Insurance Forms:

There will be a charge of $ for the completion of medical forms. Payment is due at the time that you pick up the forms. Please allow 7-10 days for the completion of these forms.

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