Patient Forms

Mohamad Eloubeidi, M.D. Eloubeidi Gastroenterology & Associates 256-237-1001

Please Bring Insurance, Driver’s License, and co-pay. We do accept debit/credit, but the CREDIT CARD company will add a 3.95% charge. Check and Cash is accepted.

Name:

Age:

Date of Birth:

Sex:

Male Female

Marital Status:

Single Married Widow Divorced Separated

Social Security No:

Referring Doctor:

Phone:

Alternate Phone:

Mailing Address:

City:

St:

Zip:

Occupation:

Employer:

Pharmacy: Local

City:

St:

Mailing Order:

Emergency Contact:

Relationship:

Phone #:

Primary Insurance Company

Policy #:

Subscribers Name:

Date of Birth:

Relationship to Patient:

Employer:

Secondary Insurance Company:

Policy #:

Subscribers Name:

Date of Birth:

Relationship to Patient:

Employer:

I hereby authorize the treating physician to furnish the above insurance company(s) all information which said insurance company(s) may request. I hereby assign to above named physician all money in which I am entitled for medical and / or surgical expense relative to medical services rendered but not to exceed my indebtedness to above named physician. I understand that I am financially responsible to treating physician for all medical services rendered and for charges not covered by this assignment.

I understand that any co-payments required by my insurance is my responsibility and is due at the time of my office visit.

I agree to notify the office of any changes of address, telephone number, or insurance carrier promptly. If I fail to do so, I will be responsible for the charges.

This gives Dr. Eloubeidi the authorization to file and receive any direct payment from my insurance company for all medical care provided to me either at his office or as an outpatient or inpatient at the hospital. In the event of non-payment for medical charges rendered, I agree to pay all costs of collection, including a reasonable attorney’s fee, court cost, and I further agree to pay the legal rate of interest on the account until paid in full. I waive, to the extent allowed by the law, all personal property rights of exception under the constitution and laws of the State of Alabama, or any other state, in connection with or related to the collection of any indebtedness incurred by me in the connection with medical services rendered.

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:

NO Show appointments will be charged to your account if we do not get a 72 hour notice of a cancellation or reschedule. $25 for office visit no show, $200 for procedure (hospital no show)

Eloubeidi Gastroenterology & Associates Mohamad Eloubeidi, MD 912 Snow St Oxford, AL 36203

HIPAA OMNIBUS RULE

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

Date

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective As the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITYS IN THE FUTURE.

Please Print Your Name

Please Sign Your Name

Legal Representative

Description of Authority

Your comments regarding Acknowledgements or consents:

HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA:

First name only Proper Sir name

Other:

Please list any other parties who can have access to your health information: (This includes step parents, grandparents and any care takers who can have access to this patient’s records):

Name:

Relationship:

Name:

Relationship:

I authorize contact from this office to confirm my appointments, treatment & billing information via:

Cell phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text message to my Cell phone

Email Confirmation

Any of the Above

I authorize information about my health be conveyed via:

Cell phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text message to my Cell phone

Email Confirmation

Any of the Above

I approve being contacted about special services, events, fund raising efforts or New Health info on behalf of this facility via:

Cell phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text message to my Cell phone

Email Confirmation

Any of the Above

In signing this HIPAA patient acknowledgement form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus rule, provide you this information with your knowledge and consent.

Office use only

As Privacy Officer, I attempted to obtain the patient’s (or representatives) signature on this Acknowledgement but did not because:

It was emergency treatment

I could not communicate with the patient

The patient refused to sign

Other (Please Describe)

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 Privacy Officer

Dr. Mohamad Eloubeidi Eloubeidi Gastroenterology & Associates 912 Snow St Oxford, AL 36203

Personal History New Patient

Today's Date:

Name:

Age:

Date of Birth:

Referred By:

Primacy Care Physician:

Describe the reason for your visit:

Medications: Please list all your current prescription and non-prescription medications, vitamins and supplements. If you have a list you may bring the list with you at your visit

Do you take any blood thinners?

None

Aspirin

Coumadin

Xarelto

Plavix

Effient

Brilinta

Pradaxa

If you need more room you may bring a complete list of medications or write on back. Thanks

Add new row

Allergies:

None

Penicillin

Sulfa

Aspirin

Iodine

Latex

Others:

Previous Hospitalizations

Add new row

Mohamad Eloubeidi, M.D. Eloubeidi Gastroenterology & Associates

Name:

DOB:

Family History

Healthy

Father

Mother

Grandparents

Siblings

Children

Deceased

Father

Mother

Grandparents

Siblings

Children

Colon Polyps

Father

Mother

Grandparents

Siblings

Children

Colon Cancer

Father

Mother

Grandparents

Siblings

Children

Ulcer Disease

Father

Mother

Grandparents

Siblings

Children

Liver Disease

Father

Mother

Grandparents

Siblings

Children

Pancreas Disease

Father

Mother

Grandparents

Siblings

Children

Crohn’s Disease

Father

Mother

Grandparents

Siblings

Children

Ulcerative colitis

Father

Mother

Grandparents

Siblings

Children

Stomach Cancer

Father

Mother

Grandparents

Siblings

Children

Diabetes Mellitus

Father

Mother

Grandparents

Siblings

Children

Heart Attack

Father

Mother

Grandparents

Siblings

Children

Breast Cancer

Father

Mother

Grandparents

Siblings

Children

Other Cancer

Father

Mother

Grandparents

Siblings

Children

Social History

Marital Status

Single Married Divorced Widowed

Occupation

Unemployed Retired

Smoking History

Never Yes

Packs per day

Years

Quit Date

Currently Smooking

Yes No

Other tobacco use

No Yes

Details

Alcohol Use (Beer Wine Liquor)

No Yes

If Yes: amount per day

IV or Recreational drug use

No Yes

IV or Recreational drug use

No Yes

Exercise

No Yes

If Yes: how much and how often:

Recent travel outside the US

No Yes

If Yes: where

Review of systems (circle all that apply at present time)

Gastro reproductive – Female

Heavy periods

Date pf last period

Last Mammogram

Last Bone Scan

Last pap smear

Immunizations list date of last inj

Hepatitis A

Hepatitis B

Flu

Pneumovax

Tetnus

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