ALABAMA EAR, NOSE & THROAT: PATIENT INFORMATION FORM

PATIENT MEDICAL HISTORY
Patient’s Name
Reason for today’s visit
List your medications and dosage
List your medications and dosage
List your medications and dosage
List your medications and dosage
Drug allergies
Prior Surgeries
Prior Surgeries
Prior Radiation:

Yes No
Prior Chemotherapy:

Yes No

Patient History

	Past	Current
Allergic rhinitis
Anxiety
Asthma
Heart Condition
Lung Disease
Diabetes
Hearing Loss
Heartburn/Reflux
High Blood Pressure
Sleep Apnea/Snoring
Kidney Failure
Sinusitis
Stroke
Smoking
Anemia
Depression
Heart Attack
Hypothyroidism
Migraine
Cancer Type
Other

FAMILY HISTORY

	MOTHER	FATHER	BROTHER	SISTER
Allergic rhinitis
Anxiety
Asthma
Heart Condition
Lung Disease
Diabetes
Hearing Loss
Heartburn/Reflux
High Blood Pressure
Sleep Apnea/Snoring
Kidney Failure
Sinusitis
Stroke
Smoking
Anemia
Depression
Heart Attack
Hypothyroidism
Migraine
Cancer Type
Other

302 Merchants Walk, Suite 100, Tuscaloosa, AL 35406

Phone: (205) 523-9300 Fax: (205) 523-9301 www.alabamaentspecialists.com

Craig M. Benoit, MD Gordon A. Shields, MD
ASSIGNMENT OF BENEFIT AGREEMENT
I hereby authorized my insurance company, including Medicare if I am Medicare Beneficiary, to make payments to Alabama Ear, Nose & Throat Specialists, LLC (ALENTS) for medcal or surgical services or items rendered to me or my dependent by ALENTS. Should my insurance carrier deny ALENTS, I understand that I am financially responsible for the changes. I authorize ALENTS to release any and all of my records to my insurer, or any other third party payer, legally responsible for the payment of medical expenses. Should failure to pay for medical services result in my account being turned over for collection from a third party, or my insurer, I understand that I am responsible for the account balance plus reasonable collection and/or attorney’s fees. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my reponsibility to update any and all personal, insurance and health information.
Patient or Legal Guardian
Signature

Clear
Date

Month Day Year
Date
302 Merchants Walk, Suite 100, Tuscaloosa, AL 35406

Phone: (205) 523-9300 Fax: (205) 523-9301 www.alabamaentspecialists.com

You have been given the Notice of Privacy Practices for Alabama Ear, Nose & Throat Specialists, LLC (AENTS) and its Physicians. This Notice describes your legal rights regarding your health information and will inform you of the legal duties and privacy practices of AENTS with respect to health information created for services generated by AENTS. If you receive services by your physician or their health care providers at a different location, you may want to ask about that office or clinic’s health information privacy policies and notices because they could be different.

Your name and signature below indicates that you have been provided with a copy of this Notice of Privacy Practices.

If you have a question regarding any of the information set forth in this Notice of Privacy Practices, please do not hesitate to call our Practice Administrator at (205) 523‐9300.
Patient Name
Date

Month Day Year
Date
Signature of Patient or Responsible Party

Clear
PERSONAL HEALTH INFORMATION
I authorize ALENTS and medical staff to discuss my healthcare information (which may include history, diagnosis, labs, test results, treatments and other health information) with the contracts listed below.

I understand that by leaving spaces blank I am indicating my choice to be a “No Information” and I do not want my information release to anyone else.
PERSONAL HEALTH INFORMATION CONTACTS:
Name 1:
Relationship to Patient
Contact Info
Name 2:
Relationship to Patient
Contact Info
Name 3:
Relationship to Patient
Contact Info
EMERGENCY CONTACT ONLY:
Name
Phone
Name

Home Phone Cell Phone Work Phone Other
EMAIL: When responding to an Email, may we include appointment, financial or medical condition information?

Yes No
VOICE MAIL: May appointment, financial or medical information be left on your answering machine or voice mail?

Yes No
Patient Signature

Clear
302 Merchants Walk, Suite 100, Tuscaloosa, AL 35406

Phone: (205) 523-9300 Fax: (205) 523-9301 www.alabamaentspecialists.com

Patient Information Form

Secondary Insurance Company:

Policy/ID #:

PATIENT MEDICAL HISTORY

Please check the appropriate boxes if you are experiencing any of the following symptoms:

ASSIGNMENT OF BENEFIT AGREEMENT

PERSONAL HEALTH INFORMATION

PERSONAL HEALTH INFORMATION CONTACTS:

EMERGENCY CONTACT ONLY: