ROHNA
PROFESSIONAL OTOLARYNGOLOGY ASSOCIATES
A DIVISION OF REGIONAL OTOLARYNGOLOGY HEAD AND NECK ASSOCIATES, LLC
HEAR MD
James M. Sumerson, MD, FACS, Stephen P. Gadomski, MD, FACS,Samir Shah, MD, FACS, Anthony Cultrara, MD, Ashmit Gupta, MD, MPH, Harry Cantrell, MD, FACS, Roy Carlson, MD
Last Name__________________________ First Name ___________________ Initial _____ Date___________
Street ______________________________ Apt/Bldg ______________________________________________
City, State, Zip _____________________________________________________________________________
Phone Home ( ____) _________________ Work ( ____) __________Ext. ______ Cell (____) _____________
Sex M ____ F ____ Birth date _______________ Age _____ Marital Status S__ M __ W__ D__
Social Security No. ________________________________ Employed Yes _____ No ______
Name of Employer __________________________________________ Phone # (____)___________________
Spouse’s Employer __________________________________________ Phone # (____)___________________
If patient is a minor, parents employer ___________________________ Phone # (____)___________________
Referred by_______________________________ Family doctor _____________________________________
Phone ___________________________________ Phone ___________________________________________
Address __________________________________Address _________________________________________
Do you want above doctor/doctors to receive a copy of this visit Yes ___ No ___ (Managed care companies usually require one)
Nearest relative NOT living with you ___________________________________________________________
Relation __________________________________________Phone # (____)____________________________
Preferred Pharmacy _________________________________Phone # (____)____________________________
Insurance Company Name ___________________________ Subscribers Name _________________________
Insurance I.D. # ____________________________________
Subscribers Birth date _______________________________Social Security No. ________________________
Employer _________________________________________Phone # (____)____________________________
Second Insurance Company Name _____________________________________________________________
Insurance I.D.# ______________________________________
Subscribers Name __________________________________________________________________________
Subscribers Birth date _______________________________Social Security No. ________________________
Employer _________________________________________Phone # (____) ___________________________
If patient is a minor please complete the following financial responsibility
Name ____________________________________________________________________________________
Address if different from patient _______________________________________________________________
_________________________________________________ Phone # (____)____________________________
Relation to patient __________________________________________________________________________
Do you or the patient have a living will or advance directive Yes _____ No _____
Name and relationship of a person who has your authorization to receive medical information on you behalf
Name____________________________________ Relationship_____________________________________
PLEASE READ and SIGN: I understand and agree that I am ultimately responsible for payment of any balance not covered by medical insurance. I certify that the information I have given is true and correct to the best of my knowledge, and I will notify you of any changes in my health status or in the above information.
I authorize release of any medical information necessary to process all claims and I authorize payment of medical benefits for services rendered by Professional Otolaryngology Associates. I further authorize release of medical information requested by another treating physician or health institution to assist in my ongoing care. I understand that some of the information released may contain but is not limited to sensitive material with regard to alcohol and drug abuse, sexually transmitted disease, behavior or mental health, HIV/AIDS, hepatitis, or other communicable diseases.
Signature _________________________ Date _______________
ROHNA Medical History Form
Last Name ________________________First Name___________________Initial______Age_____Acc#_______
Today's Date___/___/___ Birth Date___/___/___ Ref.Physician___________________Office (circle one) V H S
Please give us your medical history by completing Following:
Chief Complaint (CC) (What is your current complaint?):______________________________________________________
History of Present Illness (HPI) (To be completed by medical assistant or doctor):___________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Review of Systems (ROS) (check any symptom that you are currently experiencing)
Constitutional Symptoms: [] fever, [] chills, [] weight gain, [] weight loss, [] night sweats, [] fatigue, [] daytime somnolence, [] Failure to thrive
Organ symptoms:
Ophthalmologic: [] blurred vision, [] double vision, [] blindness, [] eye pain, [] itching, [] tearing, [] change in vision, [] field cuts, [] wears glasses
Otolaryngologic: [] hearing loss, [] ringing in ear(s), [] vertigo, [] ear pain, [] ear drainage, [] runny nose, [] nasal congestion, [] nose bleeds, [] post nasal drainage, [] sore throat, [] hoarseness, [] difficulty swallowing, [] snoring, [] headaches, [] dizziness, [] loss of sense of smell, [] throat swelling
Cardiovascular: [] chest pain, [] palpitations, [] shortness of breath on exertion, [] claudication, [] leg swelling, [] heart murmur, [] syncope
Respiratory: [] persistent cough, [] shortness of breath, [] sputum production, [] wheezing
Gastrointestinal: [] nausea, [] vomiting, [] diarrhea, [] abdominal pain, [] heartburn, [] indigestion, [] regurgitation, [] belching, [] vomiting blood, [] rectal bleeding, [] jaundice, [] constipation, [] tarry stools, [] swallowing difficulty
Genitourinary: [] frequency of urination, [] burning on urination, [] vaginal bleeding, [] vaginal drainage, [] urine retention, [] hesitancy/dribbling, [] irregular menstruation
Musculoskeletal: [] muscle or joint pain, [] back pain, [] neck pain, [] stiffness, [] weakness
Integumentary: [] rash, [] skin lesions/ulcers, [] itching, [] changes in nails, [] slow wound healing, [] change in skin color, [] paresthesias
Neurologic: [] numbness of limbs, [] weakness of limbs, [] headache, [] slurred speech, [] tremor, [] facial weakness, [] dizziness, [] loss of consciousness, [] loss of memory, [] seizures, [] unsteady gait
Psychiatric: [] change in mood, [] appetite change, [] behavior change, [] confusion, [] insomnia, [] anxiety, [] depression,
Endocrine: [] heat intolerance, [] cold intolerance, [] hair loss, [] unusual hair growth, [] excess appetite, [] excess hunger, [] excess thirst
Hematologic: [] bleeding, [] easy bruising, [] fatigue, [] swollen lymph glands, [] anemia, [] blood clots
Allergic/Immunologic: [] repetitive sneezing, [] itching in eyes, ears, nose or throat, [] food intolerance, [] congestion
Past Medical, Family, Social History (PFSH):
List your current medications including over-the-counter drugs such as aspirin, Tylenol, ibuprofen, nasal sprays, etc.
Medication and Dose Reason for Taking
_________________________________________ ____________________________________________________
_________________________________________ ____________________________________________________
_________________________________________ ____________________________________________________
_________________________________________ ____________________________________________________
_________________________________________ ____________________________________________________
_________________________________________ ____________________________________________________
Drug Allergies Type of Reaction
_________________________________________ ____________________________________________________
_________________________________________ ____________________________________________________
_________________________________________ ____________________________________________________
Past Medical History:
Have you had or do you currently have any of the following medical conditions? (Check all that apply)
[] High blood pressure [] Irregular heart beat [] Coronary artery disease [] Myocardial infarction
[] Asthma [] Tuberculosis [] Emphysema [] Pneumonia
[] Colitis (IBS) [] Stomach/duodenal ulcer [] Esophageal reflux [] Hiatal hernia
[] Cirrhosis of the liver [] Hepatitis A, B, C [] AIDS [] Bladder problems
[] Kidney problems ]] Enlarged prostate [] Osteoporosis [] Arthritis
[] Skin cancer [] Cancer, site________ [] Anxiety [] Depression
[] Thyroid disorder [] Diabetes, Type I or II [] Infectious mononucleosis [] Lupus
[] Rheumatic fever [] Blood disorder [] Anemia [] Sickle cell anemia
[] Keloids [] Lyme disease [] Epilepsy [] Migraine headaches
[] Glaucoma [] Positive HIV [] Cataracts [] High cholesterol
[] Other_____________ [] Other____________ [] Other___________ [] Other___________
Past Surgical History:
Have you had any of the following operations? Please tell us the year it was performed.
Operation Year Operation Year Operation Year
Tonsils or Adenoids _____ Hernia repair _____ Gall bladder _____
Appendix _____ Hysterectomy _____ Thyroid surgery _____
D & C _____ Coronary bypass _____ Ear surgery _____
Sinus surgery _____ Cataracts _____ Nasal surgery _____
Other _____ Other _____ Other _____
Family History:
Do any of the following diseases tent to run in your family? (Circle all that apply): Heart disease, Cancer, Tuberculosis, High blood pressure, Diabetes, Deafness, Autoimmune Disease, Bleeding disorder, Other__________________________________
If Living If Deceased
Age Current Medical Problems Age at Death Cause of Death
Biologic Father ___ _____________________________ ___ _____________________________________
Biologic Mother ___ _____________________________ ___ _____________________________________
Brothers/Sisters ___ _____________________________ ___ ____________________________________
___ _____________________________ ___ ____________________________________
___ _____________________________ ___ ____________________________________
Social History:
Tobacco:
Have you ever smoked? Y N Number of years you smoked______ Number of packs per day_____
Do you currently smoke? Y N When did you stop smoking?_______
Alcohol:
Do you drink beer, hard liquor, wine (circle all that apply)? Number of years_____. How much do you drink?_____cans/ounces/glasses per day/week (circle which ever applies)
Caffeine:
Please indicate the number of ounces per day_____. Coffee, tea, caffeinated soft drinks (circle any that apply)
Work History:
Please tell us the type of work you have done, where and when you were employed:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Pregnancy/Breast feeding/Premedication:
Are you now pregnant? Y N If so, how many weeks?______ Are you currently breast feeding? Y N
Do you require premedication with antibiotics before a dental or surgical procedure? Y N If yes, please tell us the reason_________________________________________________________________________________________________
ROHNA Financial Policy
When you come to our office, you will be asked to read and sign our financial policy. To save time, you can print this page, sign and date the financial policy and bring it with you at the time of your visit.
FINANCIAL POLICY
Our objective is to provide you with the highest quality healthcare in the most cost-effective manner. However, the ability of our Practice to achieve this objective depends greatly on your understanding of our financial policy. If you have medical insurance, we will file insurance claim forms on your behalf. We do this as a courtesy to our patients and are anxious to help you receive the maximum allowable benefits from your insurer. Even though we will file insurance claims for you, we need your active participation in the insurance claims process.
MEDICARE PATIENTS:
As a participating provider of Medicare Part B (Physician Services), our Practice will only bill you for your Medicare coinsurance, deductible and any service rendered but not covered by Medicare. All other services will be billed directly to Medicare. If you have Medicare Part A only, then the services you receive from our practice will not be covered by Medicare.
NOTE: You will be informed of services not covered by Medicare prior to these services being rendered. Your signature upon the appropriate Medicare Waiver form represents your authorization for the physician to perform these services and your acceptance of the financial responsibility for these services.
COMMERCIAL INSURANCE PATIENTS:
Remember that your insurance contract is between you and your insurer. If your insurance company pays only part of your bill or rejects your claim, you are financially responsible for the balance and are to pay it upon receipt of your statement. If your claim remains unpaid by your carrier for more than 30 days from date of services provided, the balance will become your responsibility.
NON-PARTICIPATING PLAN PATIENTS:
As the insurance industry changes, our office must make choices about with which plans to participate. Your plan may be one that covers certain areas with "out-of-network" benefits. These are usually Preferred Physician Organizations (PPO). Point of Service (POS) or indemnity plans cover a percentage of our fee based on the contract with your carrier. In some instances, your carrier will send a check directly to you, the patient, or the account guarantor rather than the provider’s office. Due to this, we offer several options for you to insure that your services are paid timely. 1) You may elect to pay your balance at or before the services are rendered and receive a 30% prompt pay discount. 2) If you prefer that we bill your insurance carrier, the full charge will have 30 days to be satisfied, with no discount (either from the check received by your insurance carrier or your own funds). If your balance is not paid within 30 days of services being rendered, your account may incur additional collection fees to satisfy the account balance.
HMO/MANAGED CARE INSURANCE PATIENTS:
Many HMO/Managed Care plans require that you obtain a referral in order to receive care from a specialist. It is your responsibility to obtain this referral if required. Unauthorized services will be the financial responsibility of the patient. Please have your referral forms and membership card available when you check in. You will be required to pay the co-pay for authorized services at the time of service. We will make every attempt to collect for our services with your insurance company, however, if your claim remains unpaid over 30 days from the date the services were rendered, the responsibility for payment will become yours.
PATIENTS WITH NO INSURANCE:
Generally, patients with no insurance are required to pay for their visits at the time of service. If special financial arrangements are deemed necessary, you will be given information regarding who to contact at the time of your visit. It is imperative you follow these instructions immediately to satisfy your financial responsibility for services provided to you. There are two options for you: 1) You may elect to pay your balance at or before the services are rendered and receive a 30% prompt pay discount or, 2) If you prefer to be billed later, the full charge will have 30 days to be satisfied with no discount. If your balance is not paid within 30 days of services being rendered, your account may incur additional collection fees to satisfy the account balance.
CANCELLATIONS AND NO SHOWS:
We require 24 hour notice of appointment cancellation to avoid a $25 charge to you.
We accept cash, personal check or Visa/Master Card as payment.
_______________________________________ ___________________________
Patient/Guarantor Signature Date
Consent For Fiber Optic Examination
Patient Name___________________________________ Date____________________
Dear Patient:
Please know that some commonly performed parts of you ENT examination in this office May include FIBER OPTIC EXAMINATIONS of the nose and/or larynx and vocal cords. If such a procedure is performed, a procedural fee will be submitted to you insurance carrier. You should know that YOUR INSURANCE CARRIER may refer to these routine parts of your specialist's consultation as PROCEDURES or even SURGICAL PROCEDURES. If our office participates with your insurance carrier, you will only be obligated to pay for any deductible, co-insurance or co pay as agreed upon by you and your carrier.
Please know that the performance of these procedures by your specialist is to give you the most accurate and best care available.
PLEASE SIGN BELOW TO ACKNOWLEDGE YOUR UNDERSTANDING OF THIS POLICY SO THAT YOUR PHYSICIAN MAY PROCEED WITH A PROCEDURE IF IT IS INDICATED.
Patient/Guardian_________________________________ Date_______________________