New Patient Forms (ENG)

Nilesh Patel MD Office (Otolaryngology, ENT)

MAKE SURE TO PRESS SUBMIT AT THE BOTTOM (Be ready with Insurance and Pharmacy address)
Please attach ALL insurance cards (Front and Back) & State ID (Front)

Cancelof
Patient Legal Name*

First NameLast Name
Patient Name*

First NameLast Name
Patient Name*

First NameLast Name
Patient Name*

First NameLast Name
Date of birth*

MonthDayYear
Month/Date/Birth Year
Date of birth*

MonthDayYear
Date
Date of birth*

MonthDayYear
Date
Date of birth*

MonthDayYear
Date
Todays Date:*

MonthDayYear
Date
REFERRING PHYSICIAN: (if none say none)*
Todays Date:*

MonthDayYear
Date
Reason for your visit?
Location of problem

EarsNoseThroatMouthOther
When did problem start?

Today1 Week AgoAlways thereOther
Do you have Pain?

NoYes
level of pain 1,2,3,4,5,6,7,8,9,10 ( 1 being least, 10 most severe)
Medications Taken for Pain

NoYes
If yes, what medication did you take?
Did it relieve you?

NoYes

Do you have any of the following?*

	Yes	No
Hypertension
Diabetes
Asthma
Acid Reflux

Have you had any of the following surgeries?*

	Yes	No
Tonsillectomy
Deviated septum repair
Sinus surgery
Ear surgery

Smoking status (TOBACCO ONLY)*

Current smokernon smokerFormer smoker
Do you drink Alcohol*

YesNo

Immediate Family ( parents, grandparents,siblings) have any following medical problems?*

	Yes	No
Easy bleeding
Sinus/Allergy problems
Cancer
Hearing Loss

Currently experiencing any of the following?*

FeverExcessive bleedingChest painDouble VisionCoughAbdominal PainHearing LossHeadacheBladder troublethyroid diseaseJoint painRashNone
Todays Date:*

MonthDayYear
Date
Height (Feet, Inches):*
Weight (Pounds):*

Please list your medications ( if you are not taking any write None*

	Medication name	Medication name
1
2
3
4
5

What medications are you Allergic to? (If None please write none)*
Demographics
Home Address*

Street Address

Apt/Floor #

CityState

Zip CodeCountry
Age:
Gender*
Marital Status*
If you do not have a cellphone please enter house phone that you can be contacted on and choose Phone for preferred method of appointment message reminders
Home Number
Please enter a valid phone number.
Cell Number (required for text reminders)*
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
How would you like to be notified for future appointments:*

TextPhone
Email: will be used to register for Patient Portal, to access records
example@example.com
Occupation:
Pharmacy name: (Please provide us with a pharmacy to send prescriptions, NYS law requires prescription be sent directly to your pharmacy) If you would like us to send it to CAPSULE they do home delivery.*
Pharmacy Address*

Street Address

Street Address Line 2

CityState

Zip Code
Pharmacy PhoneNumber*
Please enter a valid phone number.
Emergency contact Name
Emergency contact Phone Number
Please enter a valid phone number.
Primary Insurance name and Member/Subscriber ID Number (if no insurance put self pay)*
Secondary Insurance Name and Member/Subscriber ID (if none put no secondary)*
Referring Physician:
Primary Care Physician:
Race:*

AsianWhiteBlack or African AmericanOther RaceHispanicRefuse to Report
Guarantor: (Person to be billed, if different than patient: Subscriber information)

First NameLast Name
Guarantor Date of Birth:

MonthDayYear
Date
Guarantor Phone Number
Please enter a valid phone number.
Patient’s or Authorized Person’s Signature (PLEASE READ)

I the undersigned give my authorization to be treated and assign directly to Nilesh Patel MD, all medical benefits, If any, otherwise payable to me for services rendered. I understand that I am ultimately financially responsible for all approved and covered charges whether or not paid by insurance this includes deductibles, co-insurance and copayments

I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. I understand that payment is expected at the time of service and diagnostic testing and any procedures are a separate charge from the office visit.
Signature:*

Clear
Todays Date:*

MonthDayYear
Date
ACKNOWLEDGMENT AND CONSENT
By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the medical group listed at the beginning of this notice, and how I may obtain access to and control of this information. I also acknowledge and understand that I may request copies of separate notices explaining special privacy protection that apply to HIV-related information, alcohol and substance abuse treatment information, mental health information, and genetic information from my Health Care Provider. Finally, by signing below, I consent to the use and disclosure of my health information to treat me and arrange for my medical care, to seek and receive payment for services given to me, and for the business operations of the medical group, its staff, and its business associates. (Please ask the front desk for the copy of the notice.)
Signature of patient or personal representative*

Clear
Print Name of Patient or Personal representative*
Todays Date*

MonthDayYear
Date
Healthix Consent Form

I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow Nilesh Patel, MD, PC. to obtain access to my medical records through the health information exchange organization called Healthix. If I give consent, my medical records from different places where I get health care can be accessed using a statewide computer network. Healthix is a not-for-profit organization that shares information about people’s health electronically to improve the quality of healthcare and meets the privacy and security standards of HIPAA, the requirements of the federal confidentiality laws, 42 CFR Part2, and New York State Law. To learn more visit Healthix’s website at www.healthix.org.

The choice I make in this form will NOT affect my ability to get medical care. The choice I make in this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.
Home Address*

Street Address

Apt #, Floor #, House

CityState

Zip Code
Please choose one*

1. I GIVE CONSENT for Nilesh Patel, MD, PC. to access ALL of my electronichealth information through Healthix to provide health care.2. I DENY CONSENT for Nilesh Patel, MD, PC. to access my electronic health information through Healthix for any purpose.
Signature of Patient or Patient's Legal Representative*

Clear
Todays Date*

MonthDayYear
Date
Print Name (If Patient under the age of 18 then parent name goes here)*
Relationship of patient who signed
Is the patient wheelchair bound?*
Should be Empty:

Nilesh Patel MD Office (Otolaryngology, ENT)

ACKNOWLEDGMENT AND CONSENT