Patient Information

Guy Trengove-Jones, M.D., F.R.C.S.E.
301 Riverview Avenue, Suite 100
Norfolk, VA 23510
Phone: (757) 423-2166, Fax: (757) 423-2285

Date

Are you?

New Update

Chart #:

Patient Name

Last Name:

First Name:

Sex

Male Female

Social Security #:

Date of Birth:

Age:

Home Address:

Street

City

State

Zip Code

Please select your preferred method of contact:

Home Phone Work Phone Cell Phone

Home Phone:

Work Phone:

Cell Phone:

Email:

Employer/School:

Occupation:

Reason for visit:

Work Related Injury:

Yes No

Marital Status:

Married Single Divorce Widow

Emergency Contact:

Relationship:

Phone #:

Nearest Relative/Friend:

(Not living with Patient)

Phone #:

Referred By:

Primary Care Physician:

Primary Insurance:

Secondary:

Policy Holder:

Patient Other

Other:

Policy Holder's DOB:

Policy Holder's SSN:

Home Address:

Street:

City:

State:

Zip Code:

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 Patient/Responsible Party:

Date:

Witness Signature:

Release of Information

I hereby authorize treatment by Guy Trengove-Jones, M.D. to perform any services which are deemed necessary.

I hereby authorize the release of any and all medical information and/or change of information as is necessary for reimbursement from any third party or governmental agency involved in the payment of my treatment, including but not limited to: Insurance Payers, HMO's Workers Compensation carriers, Medicare, Medicaid, and Tricare. I also authorize the taking of and use of photographs; I understand these photos will become part of my medical record.

Obligation Payment

I agree to pay, and I direct and assign payment from any insurance coverage, workers compensation, government agency or disability benefits. I assign proceeds from all settlements, judgments or verdicts in favor of the undersigned from third party liability claims for injuries treated hereunder, the full amount of all charges, (including attorney's fees of thirty-three and 1/3 percent per annum on the unpaid balance due hereunder from the time when services are rendered until paid in full) to Guy Trengove-Jones, M.D.

I understand that if I have insurance, my insurance policy is a contract between myself and my insurance company. I am responsible to Guy Trengove-Jones, M.D. for any charges not covered by my insurance company, including but not limited to: Copayments, Deductibles, and fees for non-covered services. I agree to waive all homestead deed exemption rights, pay court costs, all costs of collection including, but not limited to, 33 1/3% attorney fees, and interest of 1.5% per month (18% per annum) on all unpaid balances due after 30 days. The patient and the undersigned guarantor are primarily liable for the payment of the patient's account.

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:

Date:

Signature:

Acknowledgement of Receipt of Notice for Private Practices

, have received a copy of the HIPAA notice of privacy practices and understand that protected health information may be released to other healthcare providers, hospitals, insurance companies, etc., as outlined in the privacy policy.

In general, HIPAA's privacy regulations give individuals the right to request a restriction on uses and disclosures of their protected health information. The individual is also provided the right to request confidential communications.

I wish to be contacted in the following manner:

Would you like our correspondence with you to be marked "Confidential"?

Yes No

May we identify ourselves over the phone?

Yes No

May we leave messages?

Yes No

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:

Broken Appointment Policy

When an appointment is made in our office a specific time is reserved for that patient to see the doctor and his medical staff. The appointment allows the doctor to reserve the appropriate amount of time to meet the patient's needs and also schedule other equally important patients. Broken appointments result in a loss of valuable time that could be spent with other patients in need of treatment and they are very costly to the practice.

For that reason, if a patient fails to keep an office visit, he or she will be charged a $40.00 fee for a broken appointment.

In addition, because we are not in the position to determine if an excuse is valid or not, no exceptions will be made to this policy. It is the patient's responsibility to keep their scheduled appointment.

If an appointment does need to be canceled or rescheduled for any reason, please notify our office at least 48 hours in advance of the appointed time, and no broken appointment fee will be charged. Thank you for your anticipated cooperation.

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:

Date:

Patient Signature:

Patient EMR Update

Dr. Guy Trengove-Jones is currently in the process of transitioning to the use of electronic medical records at the Plastic Surgeons of Hampton Roads Practice. The electronic medical record will contain a digital version of your paper chart that contains all patient medical history. We appreciate you taking the time to provide the information listed below, which will help establish an updated electronic patient record for you.

Patient Name:

Birth Date:

Date:

Primary Care Provider:

Address:

City:

State:

Zip Code:

Phone Number:

Pharmacy Name:

Medical History:

Please check or list any diagnosed medical conditions below:

Hypertension

Year Began:

High cholesterol

Year Began:

Hypothyroidism (low thyroid)

Year Began:

Hyperthyroidism (high thyroid)

Year Began:

Lung Condition/Disease:

COPD Emphysema Asthma

Year Began:

Diabetes Mellitus:

Type I Type II

Year Began:

GERD

Year Began:

Depression or Anxiety

Year Began:

Heart Issues

Year Began:

Autoimmune Disease

Year Began:

Rheumatoid Arthritis

Year Began:

Osteoarthritis

Year Began:

Peripheral Artery Disease

Year Began:

Vascular Disease

Year Began:

History of Skin Cancer

Year Began:

History of Breast Cancer

Year Began:

History of Cancer

Year Began:

Other(s)

Year Began:

Past Surgical Procedures/ Hospitalizations/ Serious Injuries or Fractures

Operation / Hospitalization / Injury

Month/Year

Add more

Allergies:

Do you have any food or drug allergies?

No Yes

Allergy:

Type:

Medication Food

Reaction:

Rash Hives Anaphylactic Shock

Add more

Medications

Please list below (or show us your own printed record) all prescriptions and non-prescription medications, vitamins or supplements, etc.

I TAKE NO MEDICATIONS

Please list your Pharmacy of choice:

Medication:

Dosage (mg/pill):

Times per day:

Add more

Do you take any blood thinning products such as Vitamin E, Plavix, Coumadin, or Aspirin?

No Yes

Social History

Do you smoke?

No and Never have Yes

Type of smoking (Cigarette, pipe marijuana, chew, etc)

How much

How long

Add new row

Do you drink alcohol?

No and never have Social Only Daily Beer/Wine Hard Liquor

Do you have a history of recreational drug use or abuse?

No Social Regular History

If so, what?

Current Occupation:

Please describe and family health issue below:

Family History

Mother:

Good/None Unknown

Illnesses / Reason for Death:

Father:

Good/None Unknown

Illnesses / Reason for Death:

Sibling(s):

Good/None Unknown

Illnesses / Reason for Death:

Other Hereditary Illness:

Good/None Unknown

Illnesses / Reason for Death:

Thank you for taking the time to fill out this important health documentation. Please sign below to indicate consent for the information provided above and release of electronic medical records in future purposes when warranted, by you the patient.

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 Signature:

Date:

Race/Ethnicity

As part of our health care legislation, the Federal Government is seeking information on race and ethnicity in order to measure quality care across all races and ethnic groups. You are not required to provide the information; it is completely voluntary.

Which language do you feel most comfortable speaking and reading wih your doctor or nurse?

English Spanish French Chinese German Vietnamese Korean Other

If other, please specify:

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:

Patient Signature:

Date:

HIPAA Notice of Privacy Practices

This information describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) for purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.
"Protected Health Information" is information about you, including demographic information, thay may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our staff and others outside of our office that involved in you care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice and any other use required by law.

Treatment:
We will use and disclose your proctected health information to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your proctected health information as necessary to a home healh agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment:
Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital say may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations:
We may disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

Your information will be encrypted.