New Patient Information

Last Name

First Name

Middle

Mailing Address

City

State

Zip

Home Phone

Mobile Phone

Email address

Date of Birth

Age

Social Security Number

Employer

Spouse's Name

Date of Birth

Social Security Number

Employer

Emergency Contact (Name, Relation, Phone Number)

Add Additional Contacts

INSURANCE INFORMATION

Primary Insurance

Insured's Name

ID/Policy Number

Group Number

Secondary Insurance

Insured's Name

ID/Policy Number

Group Number

I authorize Internal Medicine & Nephrology Assoc, P.A. to release any medical information necessary to process claims for the services provided. I authorize payment of government/medical benefits to Internal Medicine & Nephrology Assoc, P.A. for services provided. I understand that I remain responsible for any and all charges not met by my insurance company.

Please be aware that we DO NOT write prescriptions for any narcotics or pain medications. If necessary, we will refer you to pain management.

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

ADULT HEALTH HISTORY AND PATIENT CHECK LIST

Patient's Name

Date of Birth

Today's date

Main Reason for today's visit

Date(s) of last physical exam

ALLERGIES TO MEDICATIONS (Describe allergy or reaction)

Add Additional Allergies

PAST MEDICAL HISTORY (Indicate conditions you have or have had)

CONDITION

If yes, What year?

If yes, What type / year

HEALTH HABITS (Mark which substances you use and describe how much you use)

SUBSTANCE

If Yes, How much?

TOBACCO USE

EXERCISE AND DIET

Type of Exercise?

Type of Diet?

WOMEN'S HEALTH

Date of last menstruation?

Date of last PAP smear?

Date of last mammogram?

Number of Pregnancies

Number of Births

SEXUAL CONTACTS

LIST SYMPTOMS YOU ARE CURRENTLY HAVING

If Yes. attached it here

Add file

Please upload a file

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

Consent for Treatment

I authorize and direct Internal Medicine & Nephrology Associates, P.A., including Elias Kanaan, M.D., Hunganh Bui, M.D., and Richard Cain, NP, to perform quality care upon me.

I acknowledge that the practice of medicine is not an exact science and that no guarantees have been made to me as to the outcome of the procedures and/or treatments.

I grant this consent without duress, confusion, or pressure from my physician and/or his staff, associates, or colleagues.

Signature of Patient

Date

If the patient is a minor (less than 18 years of age) or has a legally designated representative:

Witness Signature

Relationship of Witness

Date

PRIVACY PRACTICES AUTHORIZATION FORM

For use of disclosure of Protected Health Information

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you that you receive at Internal Medicine & Nephrology Associates, P.A. Federal health privacy law requires that we have a signed and dated authorization from you. By signing this form, you give your consent to our use and disclosure of protected health information about you for specific purpose and in a specific manner.

Please list any immediate family member (spouse, parent, child) and relationship that protected health information may be disclosed to:

If you request that we do NOT disclose ANY of your PHI to a specific person (excluding disclosures necessary for the medical group's treatment, payment, and healthcare operations), please lit them below:

Acknowledgement of Review of Privacy Practices

I have reviewed this office's Notice and Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.

Patient Name

Date

Date of Birth

Signature of Patient or Personal Representative

Description of Personal Representative

Patient Financial Policy

To reduce confusion and misunderstanding between our patients and practice, we have adopted the following financial policies. If you have any questions regarding these policies, please discuss them with our office manager. We are dedicated to providing the best possible care and service to you and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment.

Unless other arrangements have been made in advance by either you or your health insurance carrier, full payment is due at the time of service. For your convenience we accept cash, check, MasterCard, and Visa.

Online Security and Privacy Notice

The healthcare industry is constantly evolving. This includes the tools healthcare professionals utilize in order to provide quality patient care. Older individuals may clearly recall when doctors wouldjot down notes on a form inside of a manila folder. That was the patient's medical file. Over the course of the past few years, patients have seen physicians use a computer to update medical files. Most familiar with the industry understand that this is due in large part to the belief that electronic health records (EHR) have many advantages.Furthermore, the majority is aware of the American Recovery and Reinvestment Act (ARRA) that stipulates that all healthcare organizations must implement the use of electronic health records by 2015. If this mandate is not satisfied, penalties will ensue. Therefore, healthcare professionals have no choice but to march into the digital world.

This mandate also coincides with the Health Insurance Portability and Accountability Act (HIPAA), which obligates all healthcare organizations to protect the interests of its patients.

One of the most advantageous features involved with electronic health records is security. While there are skeptics lingering in the industry, reputable electronic health records
specialists understand the importance of confidential medical files.

As with any online digital format, concerns of breach exist. Internet hackers possess a digital power that frightens individuals looking to conceal sensitive data. There have been cases in which medical information has been accessed by unauthorized users. While this does not occur all too frequently, the occurrences are enough to plant some cynicism in the minds of physicians and patients. These are valid concerns.

If confidential records end up in the hands of a person not privy to the information, the consequences can be overwhelming. Breach of medical records could lead to identity theft, which can destroy a person's finances, credit and reputation. Victims could seek litigation against the healthcare practice in which the breach occurred. If the breach affected multiple patients, the practice is headed down a long road of legal tribulations.

Another security concern lies within the conversion from a paper-based filing system to electronic health records. There is a potential for misplacement of data throughout this process. However, professional electronic health record vendors formulate transition strategies in order to essentially eliminate data misplacement.

How to Ensure Security and Privacy

The EHR vendor must work closely with the healthcare provider for a smooth and secure transition. The company should provide some type of comprehensive user guide for the users in the provider's practice.

There are six ways in which electronic health record entities can provide superior security and privacy solutions once the EHR is implemented.
Enhance administrative controls
Update policies and procedures
Guide employees through the stringent privacy and security training process
Run background checks on all employees Monitor physical and system accessCreate physically inaccessible systems to unauthorized individuals
Have exigencies in place for data recovery or restoration
Provide identification and verification requirements to all system users
Access the list of authorized users
Supply passwords and personal identification numbers (PINs)

Provide automatic software shutdown routines.
If you feel that your personal information has been comprimised, please reach out to our compliance officer to give full details of your experience.

Your Insurance

We have made prior arrangements with man insurers and health plans to accept an assignment of benefits. This means that we will bill those plans for which we have an agreement and will only require you to pay the authorized copayment/deductible/coinsurance at the time of service. This office's policy is to collect this copayment/deductible/coinsurance when you arrive for your appointment.
If you have insurance coverage with a plan for which we do not have a prior agreement, we will prepare and provide you with a receipt so that you may seek payment from your insurance plan. Consequently, the charges for your care and treatment are due at the time of the service.
In the event that your health plan determines a service to be "not covered," you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.
We will bill your health plan for all services provided in the hospital. Any balance due is your responsibility and is due upon receipt of a statement from our office.

Minor Patients

For all services rendered to minor patients, we will look to the adult accompanying the patient and the patient or guardian with custody for payment.

I have read and understand the financial policy of the practice, and I agree to be bound by its terms. I also understand and agree that the practice may amen such terms from time to time.

Name of the Patient / Signature

Date

Authorization for Disclosure of Medical Information

I hereby authorize (indicate name below) to disclose the following information from the health record for the purpose of continuation of medical care.

Please provide name here

To: WPPC

Address: 210 W. park Dr. Suite 104

City: Livingston

State: TX

Phone: 936-328-5820

Fax: 936-328-5824

From

Address

City

State

Zip

Phone

Fax

Patient Name

Date of Birth

Phone

Check all that apply

Progress Notes

History and Physical Exam

Laboratory Results

ER Physician Note/ ER Labs

Diagnostic Results

Discharge Summary

Other

If selected progress notes, kindly specify if last, all, or the specific dates.

If selected other, kindly specify other records.

I understand that this authorization may be revoked at any time, except to the extent that action has been taken in reliance on authorization. Unless otherwise revoked, this authorization will expire 90 days from the date the authorization was signed. The facility, its employees, officers, and physicians are hereby released from legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Patient/Guardian

Date

Relationship to patient

Do I Need a Test for PAD?

Name

Date

Peripheral Artery Disease (PAD) is a serious circulatory problem in which blood vessels that carry blood to your arms, legs, brain and kidneys become narrowed or clogged. It affects approximately 20 million Americans most over the age of 50. It may result in leg discomfort when walking, poor healing of leg sores/ulcers, blood pressure that is difficult to control or symptoms of stroke. People with PAD are at a significantly higher risk of stroke and heart attack. Answers to these questions will help determine if you are at risk for PAD and if a vascular exam will help us better assess your vascular health status.

Check All Applicable Boxes

1. Do you have foot, calf, buttock, hip or thigh discomfort (aching, fatigue, tingling, cramping or pain) when you walk which is relieved by rest?

2. Do you have a history of cardiovascular disease and experience any pain or swelling at rest in your lower legs or feet?

3. Do you have a history of cardiovascular disease of diabetes and experience any leg, foot, or toe pain that often disturbs your sleep?

4. Do you have an ulcer in your thigh, calf, ankle, foot or toe that is slow to heal?

5. Do you have diabetes and unusual hair loss or skin discoloration in your legs?

6. Do your fingers or toes feel numb or cold in response to temperature changes or stress?

7. Have you suffered a severe injury to your leg(s) or feet?

8. Do you have an infection of the leg(s) or feet that may be gangrenous (black skin tissue)?

9. Have you had blockages in your coronary or heart arteries?

Other comments or notes

Patient Signature

Date

Do I Need a Test for CVI?

Name

Date

Chronic Venous Insufficiency (CVI) is a serious circulatory problem that occurs when the venous wall and/or valves in the leg veins are not working effectively making it difficult for blood to return to the heart from the legs. It affects millions of Americans most over the age of 40. Symptoms of CVI include varicose veins, skin problems, leg and ankle sweating, tightening calves and legs that feel heavy, tired, restless, or achy. Factors that can increase the risk for CVI include pregnancy, obesity, smoking, standing or sitting for long periods of time, and not getting enough exercise. Answers to these questions will help determine if you are at risk for CVI and if a vascular exam will help us better assess your vascular health status.

Check All Applicable Boxes

1. Do you have varicose veins and heavy, tired, restless, or achy legs?

2. Do you have varicose veins with inflammation (redness, swelling, pain, and heat) in your leg(s)?

3. Do you have varicose veins and an ulcer and inflammation in your leg(s)?

4. Do you have a non-healing ulcer around your ankle or sock line with shiny or leathery looking skin?

5. Have you had a Deep Vein Thrombosis (DVT) in the past and are experiencing pain, swelling, changes in skin color, or cellulitis?

Other Comments or Notes

Patient Signature

Date

Updated STOP-Bang Questionnaire

Name

Date of Birth

Snoring?

Do you snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?

Yes No

Tired?

Do you often feel Tired, Fatigues, or Sleepy during daytime (such as falling asleep during driving or talking to someone)?

Yes No

Observed?

Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?

Yes No

Pressure?

Do you have or are being treated for High Blood Pressure?

Yes No

Body Mass Index more than 35kg/m2?

Yes No

Age older than 50 year old?

Yes No

Neck size large (Measured around Adams apple)

For male, is your shirt collar 17 inches/43 cm or larger?

Yes No

For female, is your shirt collar 16 inches/41 cm or larger?

Yes No

Gender = Male?

Yes No

ATT: PATIENTS

THERE WILL BE A $25.00 CHARGE FOR ALL NO SHOW APPOINTMENTS.

PLEASE CALL OUR OFFICE WITHIN 24 HOURS TO RESCHEDULE OR CANCEL, SO WE CAN SCHEDULE ANOTHER PATIENT FOR THAT APPOINTMENT TIME.

THANK YOU.

Your information will be encrypted.

New Patient Information

INSURANCE INFORMATION

Please be aware that we DO NOT write prescriptions for any narcotics or pain medications. If necessary, we will refer you to pain management.

ADULT HEALTH HISTORY AND PATIENT CHECK LIST

ALLERGIES TO MEDICATIONS (Describe allergy or reaction)

PAST MEDICAL HISTORY (Indicate conditions you have or have had)

ILLNESSES, INJURIES, AND OPERATIONS (Do not list those indicated above)

IMMUNIZATIONS (Indicate those received)

Mark if your blood relative(s) has had: (Men <55 years, Women <65 years)

HEALTH HABITS (Mark which substances you use and describe how much you use)

Consent for Treatment

PRIVACY PRACTICES AUTHORIZATION FORM

Acknowledgement of Review of Privacy Practices

Patient Financial Policy

Online Security and Privacy Notice

How to Ensure Security and Privacy

Your Insurance

Minor Patients

Authorization for Disclosure of Medical Information

Do I Need a Test for PAD?

Do I Need a Test for CVI?

Updated STOP-Bang Questionnaire

ATT: PATIENTS

THERE WILL BE A $25.00 CHARGE FOR ALL NO SHOW APPOINTMENTS.

PLEASE CALL OUR OFFICE WITHIN 24 HOURS TO RESCHEDULE OR CANCEL, SO WE CAN SCHEDULE ANOTHER PATIENT FOR THAT APPOINTMENT TIME.

THANK YOU.