New Patient Forms

Patient Information

Last Name

First Name

Nickname

Sex

M F

Address

Birth Date:

SS#

Marital Status

S M D W O

Preferred Contact Phone Number

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Email address

Primary Language

Marital Status

African American American Indian Asian Caucasian Pacific Islander Other

If Other is selected, please specify:

Ethnicity

Hispanic/Latino Non Hispanic/Latino Other

If Other is selected, please specify:

Referring Physician

Last Name

First Name

Office Number

Office Location

Emergency Contact

Phone

Relationship

Please print the name and relationship of the persons you authorize to receive protected health care information:

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Insurance Policy Information

POLICY HOLDER'S NAME

Last Name

First Name

Birth Date:

SS#

Relationship to Patient

Address

PRIMARY INSURANCE COMPANY

Insurance Company Name

Policy Holder's Employer

Policy Holder's Name

Policy Holder's Birth Date

Policy #

Group #

Relationship to Patient

SECONDARY INSURANCE COMPANY

Insurance Company Name

Policy Holder's Employer

Policy Holder's Name

Policy Holder's Birth Date

Policy #

Group #

Relationship to Patient

Assignment of Benefits / Release of Information

I assign and request payment of medical benefits be made to HEAD AND NECK ASSOCIATES OF ORANGE COUNTY, INC. for medical services rendered. I authorize the release of medical information necessary to process my claim. I also authorize that I may be contacted via any of the above contact information I have provided. I have read the Financial Policies and understand that I am financially responsible for any non-covered services.

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:

Financial Policies

Head and Neck Associates will submit claims to your insurance company for all medical services rendered. We will attempt to verify eligibility and benefits with your insurance company; however, this verification is not a guarantee of payment. Any expenses deemed not covered by your insurance company will be your financial responsibility.

All monies owed by the patient, i.e., office visit copayments and non-covered services or supplies are due at the time of service. Also, when applicable, coinsurance percentages and/or deductibles may be collected at the time of service. Please be aware that this office will bill only for the physicians’ services. Any other services related to your office visits, i.e., laboratory, radiology or pathology will be billed by the facility providing these services.

It is your responsibility to provide Head and Neck Associates with proof of insurance and an authorization number or referral when applicable. If these items are not provided we ask that you pay in full at the time of service.

The contract between Head and Neck Associates and your health plan, as well as the contract between you and your health plan requires that you make payment in full of all co-payments and deductible amounts deemed to be your responsibility upon claims processing. Additional discounts are forbidden by contract unless financial hardship is documented in writing by the patient.

Our office accepts the following forms of payment: most major credit cards, cash, and personal checks. A $20 service charge will be assessed to your account for any check returned by your bank.

Acknowledgement of Receipt of Notice of Privacy Practices

I hereby acknowledge receipt of the Notice of Privacy Practices being adhered to by Head and Neck Associates of Orange County. The Notice of Privacy Practices is supplied in accordance with the Privacy rule that is an integral part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

A physical copy of the HIPAA Acknowledgement can be provided upon request.

Patient Name

Patient Birth Date

Date Signed

Parent's Name (if PATIENT is minor)

Relationship to Patient (if PATIENT is minor)

Open Data Base Notice 2023

Patient we are required by the State of California to provide you with this notice of the Open Payments Database.

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

Print Patient Name (or Guardian)

Signature

Date

Patient Questionnaire

Name:

Date of Birth:

Date:

1. Age (if alive)

Mother:

Father:

Siblings:

Children

2. Health(good/bad)

Mother:

Father:

Siblings:

Children:

3. Cancer

Mother:

Father:

Siblings:

Children:

4. Tuberculosis

Mother:

Father:

Siblings:

Children:

5. Diabetes

Mother:

Father:

Siblings:

Children:

5. Heart Issues

Mother:

Father:

Siblings:

Children:

6. Hypertension

Mother:

Father:

Siblings:

Children:

7. Stroke

Mother:

Father:

Siblings:

Children:

8. Epilepsy

Mother:

Father:

Siblings:

Children:

10. Nervous Breakdown

Mother:

Father:

Siblings:

Children:

11. Asthma, hives, hayfever

Mother:

Father:

Siblings:

Children:

12. Blood disease

Mother:

Father:

Siblings:

Children:

13. Age (at death)

Mother:

Father:

Siblings:

Children:

14. Cause of death

Mother:

Father:

Siblings:

Children:

Personal History

Please select the symptoms that apply to why you are being seen by us today:

If Cancer is selected, please specify what type:

If Diabetes is selected, please specify what type:

Please list any other medical conditions:

Please list all Allergies (i.e. medications, foods, household products, etc)

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Please list ALL surgeries AND hospitalizations:

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Please list ALL diagnostic/radiological tests and WHY they were done:

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Do you exercise adequately?

No Yes

If yes, how?

Do you sleep well?

No Yes

How many hours per night do you sleep?

Do you have regular bowel movements?

Is sex satisfactory?

No Yes

Do you like your work?

No Yes

Do you work Indoors or outdoors?

How many hours a day do you watch TV?

How many hours a day do you read?

How many weeks in a year do you take vacation?

Have you ever been treated for alcoholism?

No Yes

Have you ever been treated for drug abuse?

No Yes

Please list ALL medications/supplements you take:

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Do you often feel any of the below emotions?

Depressed

Anxious

Irritable

Jumpy

Jittery

Trouble concentrating

WOMEN ONLY

Age at onset of menstrual cycle:

Usual duration of menstrual cycle:

Date of last period:

Are you regular?

No Yes

Are you:

Heavy Medium Light

Do you have Tension or Depression before your cycle?

Do you have Cramps or Pain associated with your cycle?

Do you have hot flashes?

No Yes

Children born alive:

Still born:

Miscarriages:

Children born from cesarean:

Premature:

Vaginal:

Were there any pregnancy complications?

Completed by:

Patient Other

If Other is selected, please specify:

Relationship:

Nasal/Sinus Worksheet

Name

Date of Birth

Date

Do you have nasal obstruction/blockage/congestion:

Yes No

If yes, please specify which side is worse:

Right Left Both

Do you use nasal sprays?

Never In the past Currently

If Currently is selected, please specify the name of spray:

If In the Past is selected, please specify the name of spray:

How many sinus infections have you been treated for in the past year?

Have you had a recent CT or MRI of your head/sinuses?

Yes No

If yes, please specify the date:

If yes, please specify the Location

Please check all symptoms that apply:

Nasal drainage

Decreased sense of smell

Headache

Postnasal drainage

Facial

Sneezing

Itchy eyes or nose

Watery eyes or nose

If Headache is selected, please specify which location:

Facial

Pain Pressure Fullness

Have you ever been tested for allergies?

Yes No

If yes, Result:

Have you ever had allergy shots (allergy immunotherapy)?

Yes No

If yes, for how long?

If yes, please specify date stopped:

Sino-Nasal Outcome Test (SNOT 22)

Please select the number that best describes your symptoms over the past 2 weeks.

Use this scale to describe how bad the problem when it occurs

0 - No Problem
1 - Very mild problem
2 - Mild or slight Problem
3 - Moderate problem
4 - Severe problem
5 - Worst the problem can be

Assignment of Benefits And Release of Information to Medicare

I request the payment of authorized Medicare benefits be made either to me or on my behalf to the physician(s) or supplier listed below for any services provided to me by that physician or supplier. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its’ agents, any information needed to determine benefits payable for related services. I understand my signature requests that payment be made and authorizes the release of medical information necessary to pay the claim. If other insurance coverage is listed on my claim form or electronic claim, my signature authorizes the release of information to the insurer shown. In Medicare-assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible only for the deductible, co-insurance and/or non-covered services. Deductible and co-insurance are based upon the charge determination of the Medicare carrier. This assignment is valid from today’s date and remains in effect until I, the patient, revoke this agreement.

HNA Allergy & Asthma
Tyler Basen, MD
Geeta Venkat, MD

Patient Name

Date Signed

Medicare Number

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