Patient Intake Form

Patients Personal Details

Fill the form below and we will get back soon to you for more updates.
First Name*
Last Name*
Gender*
Marital Status: *

MarriedSingleDivorcedWidow
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address
example@example.com
Cell Phone*

Area CodePhone Number
Home Phone:

Area CodePhone Number
Work Phone

Area CodePhone Number
Physicians Phone Number:

Area CodePhone Number
Referring Physician:

First NameLast Name
Have you previously attended our facility

YesNo
If Yes, state on which condition and when?
Texas Law requires Healthcare facilities to ask patients to identify their own race and ethnic background.
Language:

EnglishSpanishIndianRussian
Ethnicity:

HispanicNon-HispanicPrefer No Answer
Race:

American Indian or Alaska NativeAsian or Pacific IslanderBlack or African AmericanWhitePrefer No Answer
Patient Employment:
Patient Employment:

EmployedRetiredUnemployedDisabled
Employers Name:

First NameLast Name
Employers Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Guarantor: (where bill is to be mailed)
Check if Guarantor is same as Patient:

Yes, Patient is Guarantor
Guarantor Name

Full Name Relationship to Patient
Guarantor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List all Doctors patient is currently seeing:
Doctor's Name

First NameLast Name
Dr. Phone Number

Area CodePhone Number
Doctor's Name

First NameLast Name
Dr. Phone Number

Area CodePhone Number
Doctor's Name

First NameLast Name
Dr. Phone Number

Area CodePhone Number
Doctor's Name

First NameLast Name
Dr. Phone Number

Area CodePhone Number
Pharmacy Information:
Pharmacy Name
Pharmacy Phone Number

Area CodePhone Number
Medication List
ALLERGIES / DRUG REACTIONS:
PATIENT’S HEALTH HISTORY:
Referring M.D:
Reason for referral:
Other M.D.’s currently seeing:
PAST MEDICAL HISTORY
OTHER MEDICAL CONDITIONS OR DETAILS OF EXISTING CONDITIONS(please describe in the space below)
PAST SURGICAL HISTORY (please list below important surgeries you had in the past):
Hospitalization (Past Year)

YesNo
Name of Hospital:
Reason for hospitalization:
REVIEW OF SYSTEMS (please mark YES – Y, if you have any of following symptoms)
Constitutional

Weight LossWeight GainFeverChillsExcessive tirednessGastrointestinalNauseaVomitingPoor appetiteDiarrheaBlood in stool
Neurologic

ConfusionLightheadednessSevere headachesNumbness in feet
HEENT

Decreased visionBlurry visionDiabetic retina diseaseBleeding behind the eyeOther
Genitourinary

Burning on urinationBlood in urineFrequent urinationUrinary tract infectionsKidney stones in past
Endocrine

Excess thirstCold IntoleranceHeat IntoleranceLarge amount urine
Respiratory

Shortness of breathCoughWheezingDifficulty breathingLung disease
Musculoskeletal

Joint achesJoint SwellingMuscle achesMuscle swellingPain killer use
Hematologic

Easy bruisingBlood clotsBleeding disorder
Cardiovascular

Chest PainPalpitationsEdema / leg swellingFainting episodesLeaky heart valves
Skin

Itchy skinRashes on bodyDry skin
Other Symptoms( describe)
SOCIAL HISTORY
FAMILY HISTORY: (please list any known medical problems)
Father:
Mother:
Siblings:
Your Children:
ADDITIONAL INFORMATION: (Use this space to provide any additional information important to your health)
Insurance Information:
Subscriber ID #:
Group Name or #:
Insured Party Name:
(1) Insurance Carrier:

Name

Mailing Address

CityState / Province

Postal / Zip Code
Subscriber ID #:
Group Name or #:
Insured Party Name:
(2) Insurance Carrier:

Name

Mailing Address

CityState

Zip CodeCountry
This is to certify that I/we, the undersigned, hereby consent to and authorize the administration and performance of all treatments and operations, and the administration of any anesthetics, which, is the judgment of my physician maybe considered necessary or advisable. I/we, the undersigned agree to be financially responsible for the charges incurred by the patients and to make payments upon receipt of the periodic statements for the patient. In the event of non-payment, I/we agree that if the account is referred to an agency for collection I/we shall be required to pay all the collection expenses.

Signature: _____________________________________________ (Sign & date in person at our office)

Date: _____________________
IF YOUR INSURANCE REQUIRES AN AUTHORIZATION, PLEASE BE SURE YOU HAVE ONE CURRENT ON FILE OR YOU MAY NEED TO RESCHEDULE YOUR APPOINTMENT.
Emergency Contact Information:
Emergency Contact #1:

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Cell Number

Area CodePhone Number
Emergency Contact #2:

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Cell Number

Area CodePhone Number
I have voluntarily provided the above contact information and authorize Nephrology Associates of Greater Houston PLLC. to contact any of the above on my behalf in the event of an emergency.
Signature:_________________________________ (Sign & date in person at our office)

Date:__________________
HIPAA Release of Information:
Patients Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Appointment Information:
Please check all of the following message delivery methods that are available in case we can not reach you. Please include your daytime/work telephone number. For each number, please authorize name(s) with whom we may arrange or confirm your appointment information.
Home Phone:

Area CodePhone Number
Daytime/Work Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
A. Can we leave a detailed message on the voice mail?

YESNO
B. We may arrange or confirm your appointment with:

Self OnlySpouseMotherFatherChildOther
Name of Child / Other:
Medical Information:
With whom may we discuss or disclose your medical information?
Name Relationship Phone Number
Name Relationship Phone Number
I have received a copy of the Notice of Privacy Practices from Nephrology Associates of Greater Houston PLLC. I will inform
Nephrology Associates of Greater Houston PLLC. with any changes of the above disclosure information.

Patient's Signature ________________________________________ (Sign & date in person at our office)

Date:__________________________
Authorization to Release Medical Information:
I authorize Nephrology Associates of Greater Houston, PLLC:

Release toReceive from
Person or Organization:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Information/Copies from Medical Records of:
Patient
DOB:
Date of Service(s):
Information to be Released:

Emergency RoomRadiology ReportLab WorkRadiology Film
I understand that I may revoke this authorization in writing at any time, except to the extent that action has been reliance on it and that in any event his authorization shall expire (180) days from the date of my signature unless specified in writing here:__________________________________________________

I understand that if the recipient authorized to receive the information is not covered entity, e.g. Insurance company or non-health care provider, the released information may no longer be protected by federal and state privacy regulations.

To the Party Receiving this Information: This information has been disclosed to you from records that confidentiality may be protected by federal law. If so, federal regulations (42 CFR Part 2) prohibits you from making any further disclosure of it without specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of information or other information is not sufficient for this purpose.

For Patient Records Applicable Under Federal Law 42 CFR PART 2:

Signature/Legal Authorized Representative:________________________________

(Sign & date in person at our office)

Print Name:___________________________________ Date:_______________

Witness:______________________________________ Date:_______________

Office Policy - Please Read Carefully

We are providers for several PPO and HMO insurance plans and will be happy to file your claim for you. Co-payments are due prior to seeing the physician at the time of service. You are responsible for obtaining any necessary referral or authorization from your primary care physician. You are responsible for any non-covered charges. If you’re insurance does not make payment within 45 days, you may be asked to call them for the status of the claim.
Frequently, insurance companies may require additional information from the patient before processing a claim. If you receive such information in the mail, please fill out the form and mail it back to your insurance company as quick as possible. Failure to do so will make you responsible for the entire bill regardless of our contract status. We will expect payment of the deductible and coinsurance amounts at the time of service, or proof that your deductible has been met. We allow 60 days for processing of your insurance claims. At the end of that time, if your insurance has not paid, the entire balance becomes your responsibility.

Medicare
Nephrology Associates of Greater Houston, PLLC. accepts assignment for our Medicare patients. We will file with Medicare on your behalf but co-payment is expected at the time of service which is 20% of the Medicare allowable. If your deductible is not met we Will collect in full for services rendered.
Medicaid
Nephrology Associates of Greater Houston, PLLC. will file claims to Medicaid on your behalf. You must present a current copy of your Medicaid card at each visit.
No show Policy
Nephrology Associates of Greater Houston, PLLC. implements a NO SHOW policy. If a patient does not cancel or reschedule their appointment within 24 hours of the appointment date a $25.00 charge will be added to their account.
Notice of Privacy Practices
I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

If your account is over 120 days old (4 months) and there has not been any effort to pay the balance, the account will be reported as a bad debt to the Credit Bureau.

Please sign below that you have read this office policy and agree to it. If there is a problem, please speak to the Office Manager before seeing the doctor.

Print Name: ____________________________________ Date: _____________________

Signature: _____________________________________ (Sign & date in person at our office)
Should be Empty:

Patients Personal Details

Texas Law requires Healthcare facilities to ask patients to identify their own race and ethnic background.

Patient Employment:

Guarantor: (where bill is to be mailed)

List all Doctors patient is currently seeing:

Pharmacy Information:

PATIENT’S HEALTH HISTORY:

REVIEW OF SYSTEMS (please mark YES – Y, if you have any of following symptoms)

FAMILY HISTORY: (please list any known medical problems)

Insurance Information:

IF YOUR INSURANCE REQUIRES AN AUTHORIZATION, PLEASE BE SURE YOU HAVE ONE CURRENT ON FILE OR YOU MAY NEED TO RESCHEDULE YOUR APPOINTMENT.

Emergency Contact Information:

I have voluntarily provided the above contact information and authorize Nephrology Associates of Greater Houston PLLC. to contact any of the above on my behalf in the event of an emergency.

HIPAA Release of Information:

Appointment Information:

Medical Information:

With whom may we discuss or disclose your medical information?

Authorization to Release Medical Information:

Information/Copies from Medical Records of:

Office Policy - Please Read Carefully