Patient Education
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New Patient Information PATIENT MEDICAL HISTORY Patient Name___________________________ Date__________________ Illness: Have you ever had? (Check the correct response and indicate what year it was diagnosed/reported) No Yes Year Heart Disease ___ ___ ____ Neuritis or Neuralgia ___ ___ ____ Diabetes ___ ___ ____ Kidney Disease ___ ___ ____ Bursitis ___ ___ ____ Venereal Disease ___ ___ ____ Tuberculosis ___ ___ ____ Back Pain ___ ___ ____ Stomach Problems/Ulcer___ ___ ____ Hives/Eczema ___ ___ ____ Unusual skin rashes ___ ___ ____ Do you have allergies? ___ ___ If yes, to what?___________________________ ________________________________________ Do you smoke? ___ ___ How much?_____________________________ No Yes Year Epilepsy ___ ___ ____ Rheumatic Fever ___ ___ ____ Cancer ___ ___ ____ Arthritis ___ ___ ____ Polio or Meningitis ___ ___ ____ Frequent Headaches ___ ___ ____ Bladder Problems ___ ___ ____ Frequent Diarrhea ___ ___ ____ Frequent Constipation ___ ___ ____ Leg Pain ___ ___ ____ High Blood Pressure ___ ___ ____ Thyroid Problems ___ ___ ____ Frequent Colds/Sore Throat___ ___ ____ Do you drink alcohol? ___ ___ How much?_____________________________ Hospitalizations: Have you ever been hospitalized? If yes, explain when and why you were admitted:_________________________________________________________ ________________________________________________________________ Injuries: Have you ever had?: No Yes Year Broken or Cracked Bones ___ ___ ____ Sprains ___ ___ ____ Concussion or Head Injury ___ ___ ____ Dislocations ___ ___ ____ Back Injury ___ ___ ____ Neck Injury ___ ___ ____ Have you ever been knocked unconscious? ____No ____Yes How long were you out?_______________ Family History: Has anyone in your immediate family had?: No Yes Year Cancer ___ ___ ____ Diabetes ___ ___ ____ Heart Disease ___ ___ ____ Kidney Disease ___ ___ ____ Tuberculosis ___ ___ ____ Arthritis ___ ___ ____ High Blood Pressure ___ ___ ____ Any significant Illness? ___ ___ ____ (What?_________________________________) Are you taking any medications now?______No _________Yes What?________________________________________________ _____________________________________________________ _____________________________________________________ Please describe your present medical problem: ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________ Patient Med His 2/05 Office Payment Policy BRUCE R. HOFFEN, M.D., P.A. NEUROLOGY 515 W. SR 434 SUITE 205 LONGWOOD, FL 32750 ASSIGNMENT OF INSURANCE BENEFITS I/we assign payment directly to BRUCE R. HOFFEN, M.D., P.A. I understand that I am financially responsible for charges not paid by this assignment and that I will assist in the collection of my insurance should there be any delay in payment. PAYMENT POLICY 1. I/we understand that payment is due at the time of service. Copayments, coinsurance and deductibles can be paid by cash, personal checks, MasterCard or Visa. There is a $25 fee for returned checks. Medicare patients are responsible for their deductibles and charges for non-covered services. 2. BRUCE R. HOFFEN, M.D., P.A. will file paperwork for secondary insurance if the correct information is supplied and deductibles have been met. 3. I/we understand that I am responsible for keeping my appointment. A $25 fee will be assessed for all cancellations with less than 24 hours notice or for failure to appear for appointments. 4. Failure to pay bills owed to BRUCE R. HOFFEN, M.D., P.A. may result in collection action. I/we understand that if my account is sent to collections, I will be held responsible for collection fees and/or attorney fees. 5. I/WE AM ULTIMATELY RESPONSIBLE FOR MY BILL. If my insurance company has not paid within 45 days following treatment, I understand the entire balance becomes due. NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT Our notice of Privacy Practices provides information about how we may use and release protected health information about you. You have the right to review our Notice before signing this form. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy by writing our practice or requesting a copy from our front desk staff. By signing this form, you consent to our use and release of protected health information about you for treatment, payment and health care operations as described in our Notice. You have the right to revoke this consent, in writing, except where we have already made releases in reliance on your prior consent. Please sign below to acknowledge the information on this document. __________________________________________________ Patient /Guarantor Signature __________________________________________________ Witness __________________________________________________ Please Print _____________________ Date Payment Policy 2/05 Patient Information Form BRUCE R. HOFFEN, M.D., P.A. Patient Information NEUROLOGY 515 W. SR 434 Suite 205 Longwood, FL 32750 (407) 332-5141 Telephone (407) 332-6819 Facsimile Name of Patient: _________________________________________________ Street Address: __________________________________________________ City____________________ State______ Zip Code_______________________ Home Telephone Number: ___________________________________________ Cellphone Telephone Number: ________________________________________ E-mail Address____________________________________________________ Social Security Number: _____________________________________________ Drivers License Number: ____________________________________________ Patient Date of Birth:___________ Patient Age_____ Marital Status__________ Who referred you to us? ____________________________________ Employment Information: Occupation:___________________ Years at present job______________ Name of Employer:____________________________________________ Address of Employer: __________________________________________ Work Phone Number: __________________________________________ Insurance Information Insured's Name (if different from Patient)__________________ Relationship to Patient_________ Date of Birth:______________________ Social Security #______________________ Name of Employer:____________________________________________ Address of Employer: __________________________________________ Work Phone Number: __________________________________________ Name of Insurance Company: ____________________________________________ Address of Company: ___________________________________________________ Phone Number:_________________ Group Number: _________________________ Is this related to an Automobile Accident? ______yes ______no Claim Number_______________________ Date of Accident(if applicable)____________ Is this covered under Worker's Compensation? ______yes ______no Claim Number_______________________ Date of Accident(if applicable)____________ What is the name of your Insurance Adjuster?__________________________________ Patientinfo.doc 2/05 |
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