Mississippi Vein Clinic - All Forms Combined (New)

CHRONIC CONDITIONS
Please list any other chronic conditions that you are prescribed medication. If none, write 'NONE'*
Please list any providers that follow you for chronic conditions or wellness. If none, write 'NONE'*
What is the reason for your visit?*
Do you have bulging veins on outside of legs?*

YesNo
Describe the location of the veins that concern you:*

Consultation Visit
Mississippi Vein Institute
111 Fountains Blvd
Madison, MS 39110
601-707-7026

Your consultation visit will consist of:
- Duplex venous ultrasound of your legs
- Physician Evaluation and Consultation
- Discussion of proposed Treatment Plan
- Consultation regarding insurance benefits
- Discussion regarding scheduling of treatment
This appointment typically takes approximately 2 hours from your scheduled appointment time. You will see four different medical professionals. During this visit, the plan to treat your venous disease will be explained and your insurance benefits will be reviewed. You will be able to schedule your treatment, if you would like. You will be given a folder that contains information regarding your procedure and recovery. The folder will provide pre and post op instructions, cell numbers of our staff, consents for your reivew and documentation of the benefits that we discussed with you.

Each insurance carrier sets their own cost or "allowable fee" for this visit. An ultrasound examination is performed in conjunction with the physician evaluation. The amount due will depend on how your insurance carrier covers this visit and the specifics of your policy. Some policies charge just a co-pay, some charge the co-insurnace (usually 20-30% of allowable fees), or the visit could go toward your deductible. If your carrier assigns your financial responsibility as a co-pay or co-insurance, the patient responsibility is usually $50-400. However, if your visit goes toward your deductible the amount due will depend upon the specifics of your policy.

Please complete the paperwork required for this visit prior to your appointment time. You can complete the forms online by clicking on this link: msvein-forms.com. We can send the forms through email if you have the ability to the print hte forms. We can also mail the forms to you. If you are unable to complete your paperwork prior to your visit, please arrive at Mississippi Vein Insititute at least 45 minutes prior to your appointment time in order to complete forms and be checked in by the time your visit should start.

We look forwad to seeing you soon.

Insurance & Release

FORM #3
Patient Name*

First NameLast Name
Primary Insurance Carrier:
Primary Policy Holder's Name:

First NameLast Name
Primary Policy Holder's Date of Birth:*

MonthDayYear
Primary Policy Holder's SSN:
Patient's SSN:*
RELEASE
Mississippi Vein Institute will create documents and maintain records of your treatment including: history & physical examination, ultrasound results, diagnosis and treatment. Pictures will be taken and maintained as part of the record to aid in measuring the results of treatment. These pictures may be requested by your insurance company to document your disease status. Mississippi Vein Institute may use my health care information and may disclose such information to my insurance company and their agents to obtain payment for the services. Non identifying pictures will be taken to record before and after treatment results and may be used for educational and marketing purposes.

ASSIGNMENT
I certify that I have medical health insurance with the above listed carrier. I directly assign to Mississippi Vein Institute all insurance benefits for the services rendered. I understand that I am financially responsible for all charges not paid by insurance. I authorize my signature on all insurance submissions.
Signature:

__________________________________

Today's Date:

__________________________________

Common Ownership Disclosure

FORM #4
Name*

First NameLast Name
Date of Birth*

MonthDayYear
The owners of Mississippi Vein Institute, MS Medical Aesthetics, The Men's Clinic - Brandon and The Men’s Clinic-Madison also have a financial interest in Madison Medical Compounding Pharmacy.

By signing below, you are acknowledging we have disclosed this common financial interest to you.
Signature:

__________________________________

Today's Date:

__________________________________

HIPAA Disclosure Form

FORM #5
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Federal legislation concerning patient privacy requires health care providers, health insurance companies, and other health related organizations to bolster their privacy practices as of April 14, 2003.

Our Health Information Privacy Practices are available for your review. You may receive a paper copy upon your request.

I acknowledge that I was informed that the privacy practices of Mississippi Vein Institute are available for my review.
Signature:

__________________________________

Today's Date:

__________________________________
Should be Empty:

Demographics & Health History

PATIENT INFORMATION

VEINS

HISTORY

CHRONIC CONDITIONS

FUNCTIONAL IMPAIRMENT

Consultation Visit

Insurance & Release

Common Ownership Disclosure

HIPAA Disclosure Form