NEW PATIENT FORMS - ENGLISH

PATIENT EMPLOYER INFORMATION

INSURANCE POLICY HOLDER INFORMATION

I certify that the information provided above is compleb and accurato 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.

ADULT HEALTH HISTORY QUESTIONNAIRE
CONFIDENTIAL

MEDICATIONS/ALLERGIES

List current medications you take and/or allergies you have:

WOMEN ONLY

MEN & WOMEN

HOSPITALIZATIONS/SURGERIES INJURIES

FAMILY HISTORY

Office Policy

1. Co-Pays are payable at time of visit. Co-Pays need to be paid each time you visit with the doctor even on follow up visits.
2. Self-Pay patients must pay CASH ONLY! No Checks/Credit Cards will be accepted. Self-Pay patients must pay each time they have an office visit.
3. Patients who take medications on a regular basis need appointments every three months.
4. Any patient that needs medication refills after 3 months need to have an office visit first.
5. Antibiotics will not be prescribed over the phone. In an event of an emergency, Dr. Khan will give a 3-Day supply and patient must follow up within 48-Hours.
6. Referrals and pre certifications will not be done if patient hasn't had an office visit within 3 months.
7. Patient must notify us prior to office visit of any insurance changes otherwise insurance company might not pay and it will be the patient's responsibility.
8. Any address or telephone number changes must be changed with the front desk.
9. Kindly notify us 24 hours prior to cancellation of appointment to avoid $25.00 no-show fee.
10. Blood test will only be done with a prescription.
11. AS OF SEPTEMBER 1st, 2012, A $10.00 FEE WILL BE CHARGED TO COMPLETE DISABILITY FORMS.
12. Effective January 1", 2015 completion of all medicals forms will be a charge of $10.00.

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.

HIPAA CONSENT

Patient Record of Disclosures

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of their home.

I acknowledge that I have read a copy of the Notice of Privacy Practices for HIPAA.

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.

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly, will constitute an adequate record

Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency.

Record of disclosure of Protected Health Information

(The section below is to be completed by Office Staff only when disclosing records)

• (1) Check this box if the disclosure is authorized
• (2) Type key T= Treatment Records; P= Payment Information; O= Healthcare Operations
• (3) Enter how disclosure was made: F= Fax; P= Phone; E= Email; M= Mail; O= Other

Patient Responsibly For Follow-Up Care

Acknowledgement and Promise

acknowledge and understand that even with the exercise of good medical care. a physician cannot always assure the successful treatment and resolution of my medical problems. Therefore. I understand that it is important that any and all recommendations by my physician are followed promptly and completely in order to increase the like hood of a positive and healthy treatment/outcome.

I acknowledge and understand that if my physician prescribes medicine. it is my sole responsibility to fill the prescription promptly and to take the medicine as directed to completion.

I also understand that if my physician refers me to see another doctor or for a test such as a blood test, and MRI, or CT scan, or other diagnostic study, this recommendation is important and essential to the ultimate success of my treatment/outcome. I understand that it is my sole responsibility to see the consulting physician or to obtain the recommended test as promptly as possible. I recognize that it is not possible for my physician or her office to follow-up to ensure that I have followed her recommendations. Therefore. I understand that if I fail to promptly see the recommended specialist or obtain the testing for which I was referred, this may compromise my current health or increase future health risks as the result of the failure to follow the advice of my doctors.

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.

Do I Need a Test for PAD?

Peripheral Arterial Disease (PAD) is a serious circulatory problem in which the blood vessels that carry blood to your arms, legs, brain, or kidneys, become narrowed or clogged. It affects over 8 million Americans, most over the age of 50. It may result in leg discomfort with walking, poor healing of leg sores/ulcers, difficult to control blood pressure, or symptoms of stroke. People with PAD are at significantly increased risk for stroke and heart attack. Answers to these questions will determine if you are at risk for PAD and if a vascular exam will help us better assess your vascular health status.

Select Yes or No

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.