New Patient Information Form

Please correct the errors described below.

Complete and submit securely to our office prior to your first office visit. Thank you.

Southlake Kidney Specialists, PLLC Office policy:

Appointments

Patients are seen in the office by appointment only. Please call (817) 233-6923 to make an appointment. For your initial visit, we request you to download and fill out the forms in Forms section. If this is not possible, please arrive in the office fifteen minutes early to fill out necessary paperwork.

Cancellation / No-Show Policy

If you can't make it to your appointment, please call our office before 24 hours prior to your scheduled appointment. Your cancellation will be considered late if it's made within 24 hours of this scheduled time.

Southlake Kidney Specialists implements a NO SHOW policy. If a patient does not cancel or reschedule their appointment within 24 hours of the appointment date, our office will charge $25.00 for all late cancellations and no-shows. While we make every effort to avoid this, due to occasional scheduling changes, you may receive a call to change your appointment time.

Insurance and Billing

Dr. Devidoss is a provider for several PPO and HMO insurance plans and her office will be happy to file your claim for you. Copayments are due prior to seeing the physician at the time of service. You are responsible for obtaining any necessary referral or authorization from your primary care physician. You are responsible for any non-covered charges. If your insurance does not make payment within 45 days, you may be asked to call them for the status of the claim.

Frequently, insurance companies may require additional information from the patient prior to processing a claim. If you receive such information in the mail, please fill out the form and mail it back to your insurance company as quickly as possible. Failure to do so will make you responsible for the entire bill regardless of the contract status. We will expect payment of the deductible and coinsurance amount at the time of your service, or proof that your deductible has been met. We allow 60 days for processing of your insurance claims. At the end of that time, if your insurance has not paid, the entire balance becomes your responsibility.

-Medicare: Dr. Devidoss accepts assignments for Medicare patients. We will file with Medicare on your behalf; however, co-payment is expected at the time of service which is 20% of the Medicare allowable. If your deductible is not met, we will collect in full for services rendered.

-Medicaid: Dr. Devidoss's office will file claims to Medicaid on your behalf. You must present a current copy of your Medicaid card at each visit.

If your account is over 120 days old (4 months) and there has not been any effort to pay the balance, the account will be reported as a bad debt to the Credit Bureau.

Please sign below that you have read and agreed this office policy.

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.

Basic Information

Demographics

Emergency Contact

Financial Information

Responsible Party

If you chose "Someone Else", please fill out the following:

Relationship to Contact

Method of Payment

If you chose "Insurance ", please fill out the following:

PRIMARY INSURANCE POLICY

If you are not the primary policy holder, please fill out the following:

SECONDARY INSURANCE POLICY

If you are not the secondary policy holder, please fill out the following:

Additional Information

Please list your preferred pharmacies in order of preference

Add pharmacy

PAST MEDICAL HISTORY - COMMON DISEASES

Do you have a personal history of any of the following?

Kidney Disease

Diabetes

High Blood Pressure

Ischemic Heart Disease

Cancer

PAST MEDICAL HISTORY - ADDITIONAL CONDITIONS

Do you have a personal history of any of the following?

EENT

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

OB History

Musculoskeletal

Neurological

Psychiatric

Hematology

Immuno/ Allergy

PAST MEDICAL HISTORY - SURGERY HISTORY

FAMILY HISTORY - ILLNESSES

Do the following family members have any of the following medical conditions?

FAMILY HISTORY - STATUS

Father

Mother

HIPAA COMPLIANCE PATIENT CONSENT FORM

Southlake Kidney Specialists Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of this notice may change. If so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

  1. Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
  2. The practice reserves the right to change the privacy policy as allowed by law.
  3. The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
  4. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
  5. The practice may condition receipt of treatment upon execution of this 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.

VERY IMPORTANT: BRING ALL YOUR MEDICATlONS IN A PLASTIC BAG OR CONTAINER WITH YOU TO YOUR APPOINTMENT.

List name and number of your LOCAL pharmacy:

LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING BELOW:

Example: Coreg
Example: 25mg
Example: 1 daily

Add medication

LIST ANY OVER THE COUNTER MEDS

Add over-the-counter medication

Your information will be encrypted.

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