New Patient Forms

PATIENT INFORMATION

Patient:

Date of Birth:

Age:

Soc. Sec. #

Address (Local)

City

Zip:

Hm. Ph.

Other Ph.

Address (Local)

City

Zip:

Hm. Ph.

Other Ph.

Spouse's Parent's

Name:

Date of Birth:

Soc. Sec. #

Person Responsible for Bill:

Relationship:

Billing Address:

Zip:

Hm. Ph.

Other Ph.

Employment Status:

PT student

FT student

PT work

FT work

Medical Leave of absence

Retired

Active Military – USA

Active Military – Oversea

Minor not of school age

Patient’s Employer & Occupation:

Guardian’s Status (if patient is under 18):

PT student

FT student

PT work

FT work

Medical Leave of absence

Retired

Active Military – USA

Active Military – Oversea

Minor not of school age

Guardian’s Employer & Occupation:

Employer Address:

PERSON TO CONTACT IN CASE OF EMERGENCY

Name:

Relationship to Patient:

Phone 1:

Phone 2:

Patient's Regular Physician & Clinic Name:

Phone:

How were you referred to us? :

MEDICAL INFORMATION

Medical Problem or Reason for Today's Visit:

Date of Injury (if applicable):

Related to work?

Auto Accident?

Are you being treated for any ongoing or chronic conditions?

INSURANCE INFORMATION

Medical Insurance (1):

Name of Policy Holder

Policy Holder Date of Birth:

Relationship to patient:

Policy Holder Social Security Number:

Name of Employer:

Group Number:

Identification Number

Medical Insurance (2):

Identification Number

Policy Holder

Policy Holder Date of Birth:

Relationship to patient:

Policy Holder Social Security Number

Name of Employer:

PRIOR TO TREATMENT, PLEASE READ CAREFULLY AND SIGN BELOW

I Herby authorize the release of medical and billing information, by Carl L. de los Reyes, M.D., to my treating physician(s), insurance company, and the responsible party named above on behalf of myself and/or my dependents, as necessary for the continuation of my medical care. I also agree to pay, in a current manner, any balance of professional service charges over and above my insurance payments.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

IF YOU WISH OUR OFFICE TO FILE YOUR INSURANCE CLAIMS, PLEASE SIGN BELOW

I herby authorize payment of medical benefits for services to Carl L. de los Reyes, M.D., on behalf of myself and/or my dependents.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

I HAVE BEEN MADE AWARE OF MY RIGHTS AND REVIEWED A COPY OF THE HIPAA PRIVACY POLICY.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITY

I request that payment of authorized insurance Company/Medicare benefits be made on my behalf to Carl L. de los Reyes, M.D. for any services furnished to me by him I further authorize Carl L. de los Reyes, M.D. to release to my health insurance carrier(s) or the Health Care Financing Administration and its agents, any information needed to determine these benefits or the benefits payable for related services which may include information on sexually transmitted diseases, any labs including HIV results, psychiatric information, or any substance or alcohol abuse. My signature below authorizes my physician to submit claims without my signature on each and every claim to be submitted.

I understand that I am responsible for any amount not covered by insurance.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

SIGNATURE OF PATIENT OR LEGAL GUARDIAN

Date:

Provider of the following insurance plans:

BCBS
HMA
CIGNA HealthCare
HMSA HMO (Hawaii IPA and Pacific Medical)
HMSA (PPO and 65c/65c+)
Kaiser Added Choice
Medicare
The Queen’s Health Systems Health Care Plan
Tricare Standard
University Health Alliance (including UHA 2000)
UNICARE Life & Health Insurance

Aetna
American Maritime Officers Plan HMA
Desert
Guarantee Trust Life Insurance Company
HYGEIA
Nat'l Elevator Industry Health
Nippon Life Insurance of America
Time-Warner (Oceanic Cable)
Deseret Mutual Benefit Administrators
United HealthCare

MEDICAL RECORDS RELEASE

I hereby understand that the release of medical records from Carl L. de los Reyes, M.D. needs to be requested by completing a medical records release form. I also understand that a processing fee of $.50 per page will be charged.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

SIGNATURE OF PATIENT OR LEGAL GUARDIAN

Date:

HIPAA AUTHORIZATION TO RELEASE RECORDS

I authorize the use and/or disclosure of my protected health information as described below:

1. My authorization applies to the information described below. Only this information may be used and/or disclosed pursuant to this authorization

(check all that apply):

All medical records All medical records except:

Clinical notes

HIV test results

Genetic test results

Lab/Imaging Reports

Restrict to the following dates/conditions:

X-ray Film(s)

Other (specify)

If Restrict to the following dates/conditions:

If others, Specify:

2. The doctor and his/her staff have my permission to speak to the following spouse, family member, relative or friend regarding my medical information and treatment.

Add new row

3. I understand that if my protected health information is disclosed to someone who is not required to comply with the federal privacy protection regulations, then the information may be re-disclosed and would no longer be protected.

4. This authorization gives the doctor and his/her staff permission to leave messages regarding my appointments or health information on my answering machine/voice mail.

5. I understand that I have a right to revoke this authorization at any time. My revocation must be in writing (e.g. a letter) addressed to the doctor. I am aware that my revocation is not effective to the extent that persons I have authorized to use and/or disclose my protected health information have acted in reliance upon this authorization.

6. This authorization shall cover the period of time from my first visit to my last visit. I release the doctor and staff from all legal responsibility that may arise from this authorization.

7. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from the doctor, nor will it affect my eligibility for benefits.

8. My protected health information will be used or disclosed upon request for the following purposes

(check as many as apply):

Personal records

Continued medical care

Insurance claim

Legal Action

Other (specify)

If other, specify:

9. I understand that I have a right to inspect and copy my own protected health information to be used or disclosed in accordance with the requirements of the federal privacy protection regulations:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date:

Print Name

CONSENT FOR USE OF PHOTOGRAPHS AND RECORDS

I hereby grant permission for the use of any of my medical records, illustrations, photographs or other imaging records created in my case, for use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery, Inc.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Witness Signature

Date:

History Intake Form

Please answer all of the questions as accurately as possible. If you do not understand the question, please ask for assistance.

Primary Care Doctor:

Approximate type & amount per day of

Alcohol:

Coffee:

Aspirin:

If former smoker, date quit:

Weight

Height:

List Drug allergies:

List previous surgeries or major illnesses and dates:

List any medications you are taking, including non-prescription drugs, vitamins, and herbals:

Family History

Has any blood relative ever had the following:

Breast Cancer

Melanoma

Stroke

High blood pressure

Heart Disease

Diabetes

Kidney disease

Depression

Colon Cancer

Past Medical History

Review of Systems

Women only: Bra size:

Age period began

Date of last mammogram

Do you do regular breast self-examinations

Number or pregnancies.

Did you breast feed?

Yes No

Breast lump or discharge

Yes No

I VERIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of patient or guardian if minor

Date:

Your information will be encrypted.