New Patient Packet - Tuscaloosa Surgical Associates, P.C.

New Patient Packet - Tuscaloosa Surgical Associates, P.C.
PATIENT INFORMATION
Today's Date

MonthDayYear
Date
First
MI
Last
Date of Birth

MonthDayYear
Date
Age
Street Address
City
State
Zip Code
Social Security #
Home Phone
Cell Phone
Email Address
example@example.com
Employer
Employer Phone
Gender

MaleFemale
Marital Status

SingleMarriedDivorcedWidowed
Primary Physician
Referring Physician
Whom may we notify in case of emergency:
Name
Relationship
Phone
INSURANCE INFORMATION
Primary Insurance
Copay Amount
Policy #
Group #
Effective Date

MonthDayYear
Date
Name of Insured
Relationship
Date of Birth

MonthDayYear
Date
Secondary Insurance Policy
Secondary Insurance
Copay Amount
Policy #
Group #
Effective Date

MonthDayYear
Date
Name of Insured
Relationship
Date of Birth

MonthDayYear
Date
Race

WhiteBlackHispanicAsianAmerican IndianHawaiian/Pacific Islander
Languages

EnglishSpanishFrenchItalianChineseVietnamese
Ethnicity

Not HispanicHispanic
I understand by signing below I am financially responsible for all services rendered by Tuscaloosa Surgical Associates, P.C. I authorize Tuscaloosa Surgical Associates P.C. to release all information necessary to secure payment by my insurance company to Tuscaloosa Surgical Associates, P.C.
Patient Signature

Clear
Date

MonthDayYear
Date
STATEMENT OF FINANCIAL RESPONSIBILITY
We appreciate you choosing our practice for your medical care. We strive to provide you with the best possible care available. We file insurance claims for our services with most insurance carriers. It is your responsibility to determine if Tuscaloosa Surgical Associates, P.C. (TSA) is in network with your insurance carrier. You are responsible for all allowable charges not covered by your insurance, including co-pays, co-insurance, deductibles, and non-covered charges. If you do not have insurance, we do provide a hardship financial plan that can be suited to your personal situation. You must complete this form, and make payments according to the payment schedule.

By signing below, I authorize Tuscaloosa Surgical Associates, P.C. to furnish information concerning my illness and treatment to my insurance company, and assign to the physicians all payments for medical services rendered to myself or minor dependents. I understand TSA may employ nurse practitioners or physician assistants and acknowledge I am responsible for all services rendered by the practice. I understand if my account is delinquent, it will be reviewed and may be placed with a collection agency. I understand this is a legal and lawful debt, and agree to pay all costs incurred in the collection of this debt. This includes any and all collection agency fees (33 1/3%), attorney fees and/or court costs, if necessary. I waive now and forever my right of exemption under the laws of the constitution and the State of Alabama and any other State.

I also agree, in order to service my account or collect monies I may owe, TSA and/or its agents may contact me by telephone at any telephone number associated with my account, including wireless telephone numbers, which may result in charges to me. TSA and/or its agents may also contact me by text message or email, using any email address I have provided. Methods of contact may include the use of pre-recorded/artificial messages and/or automatic dialing systems.
Patient Name
Date

MonthDayYear
Date
Responsible Party Signature

Clear
ACKNOWLEDGMENT OF OUR NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that I have received or have been given the opportunity to receive a copy of Tuscaloosa Surgical Associates, P.C. Notice of Privacy Practices. By signing below I am "only" giving acknowledgment that I have received or have had the opportunity to receive the Notice of our Privacy Practices.
Patient Name (Type or Print)
Patient's Date of Birth

MonthDayYear
Date
Signature of Pätient or Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
HIPAA AUTHORIZATION STATEMENT
Please list any providers, treatment facilities, or any other person with whom we may share protected health information, or speak to regarding your medical treatment. This form will be kept on file for one year and you will not have to sign a separate consent for the names listed below.
Name
Phone/Fax
Name
Phone/Fax
Name
Phone/Fax
Name
Phone/Fax
PATIENT NAME
SIGNATURE

Clear
DATE

MonthDayYear
Date
Office Policies
Please initial each line to confirm you have read, understand and agree to the following:
Disability/FMLA Paperwork: We will complete ONE form per procedure/surgery. There will be a $15.00 charge for any additional forms requested. This includes secondary insurance or additional forms requested by your job.
No Show: We appreciate a 24 hour notice for cancelled or rescheduled appointments There will be a $20.00 "No Show Fee" for appointments cancelled less than 24 hours.
Referrals: I understand if my insurance requires a referral from my primary care doctor, it is my responsibility to obtain a referral before being seen by a physician. If my claim is denied for "No Referral" I will be responsible for the any charges for services rendered.
Co Pays: All co pays are due at the time services are rendered.
Medication Refills: All refills must be requested at the time of your appointment. Requests for refills outside of an appointment may be subject to a $25.00 charge.
Consent to Receive Phone Calls: I agree to allow Tuscaloosa Surgical Associates, P.C. to leave messages with any of the phone numbers I have provided. These messages may include appointment reminders and other important information. No protected health information will be left in the message.
CONSENT TO REVIEW PHARMACY HISTORY
In order to provide the best care and treatment, and avoid any possible drug interactions, it may be necessary for Tuscaloosa Surgical Associates, P.C. to review your prescription history.
I consent to the review of my prescription history.
I do not consent to the review of my prescription history.
***I understand not giving consent may result in some medications not being prescribed for me.
Signature

Clear
Date

MonthDayYear
Date
HEALTH HISTORY
Name
Today's Date

MonthDayYear
Date
Age
Birthdate

MonthDayYear
Date
What is your reason for visit?
REVIEW OF SYSTEMS
Check + for symptoms you currently have or have had in the past year.
General

FatigueFeverHeadacheLoss of SleepLoss of WeightSweats
Muscle/Joint/Bone (Pain, Weakness, Numbness)

ArmsBackFeetHandsHipsLegsNeckShoulders
CARDIOVASCULAR

Chest PainHigh Blood PressureIrregular Heart BeatLow Blood PressurePoor CirculationRapid Heart BeatSwelling of Ankles
Lymphatic

Swollen Lymph GlandsLower Extremity Swelling
Eye, Ear, Nose, Throat

Blurred VisionDifficulty SwallowingEaracheHay HeverHoarsenessLoss of HearingNose BleedsRinging In EarsSinus Congestion
Respiratory

Persistent CoughShortness of BreathWheezing
Skin

Bruise EasilyHivesItchingChange in MolesRashSore That Won't Heal
Neurologic

DizzinessFaintingForgetfulnessHeadacheTingling in HandsTingling in Feet
Psychologic

DepressionNervousnessPanic Attacks
Genito/Urinary

Blood in UrineFrequent UrinationPainful Urination
Gastrointestinal

Appetite PoorBloatingBowel ChangesConstipiationDiarrheaHemorrhoidsIndigestionNauseaRectal BleedingRefluxStomach PainVomitingUnexplained Weight Loss
MEN Only - Check any that apply

Breast LumpLump in TesticlesSore on penis
WOMEN Only - Check any that apply

Bleeding between PeriodsBreast LumpExtreme Menstrual PainHot FlashesNipple DischargePainful IntercourseVaginal Discharge
Are you pregnant?

NoYes
Date of last menstrual period

MonthDayYear
Date
Date of last Pap Smear

MonthDayYear
Date
Have you had a mammogram?

YesNo
Date of most recent mammogram

MonthDayYear
Date
Have you had a colonoscopy?

YesNo
If you have had a colonoscopy, what date was your most recent?

MonthDayYear
Date
Past Medical History

AlcoholismAnemiaAnorexia/BulimiaArthritisAsthmaBarrett's EsophagusBleeding DisordersBreast LumpBronchitisCancerChemical DependencyChicken PoxColon PolypChronic Fatigue Syndrome (CFS)CystitisDiabetesEmphysemaEpilepsyFibromyalgiaGall StonesGoiterHeart DiseaseHepatitisHerniaHerpesHigh CholestrolHIV PositiveIrritable Bowel Syndrome (IBS)Kidney DiseaseLiver DiseaseMigraine HeadachesMononucleosisMultiple SclerosisPacemakerPeptic UlcersPenumoniaPsychiatric CareRheumatic FeverSinusitisStrokeSuicide AttemptThyroid ProblemsTonsillitisTuberculosisVaginal Infections
List allergies to any medication or substances you may have.
Pharmacy Name
Pharmacy Phone
Family History

Fill in health information about your family
Please share any health history of your father, mother, brothers, sisters: ages, states of health, age(s) of deaths, and causes of death.
Check any of these if your blood relatives had any of the following:

ArthritisAsthma, Hay FeverCancerChemical DependencyDiabetesHeart DiseaseHigh Blood PressureKidney DiseaseTuberculosisStroke
If you answered yes to any of the above, please list the relationship of the individuals to you
Please tell us your Past Medical History. This includes any hospitalizations, year, recurring hospitalization and outcomes.
Please list your pregnancy history: Year of birth, sex of birth, complications if any.
Health Habits
How much caffeine do you consume if any?
Do you consume drugs?

YesNo
Do you consume alcohol?

YesNo
Alcohol consumption: Occasional, Moderate, Daily?

OccasionalModerateDaily
Do you smoke?

YesNo
If yes, how many packs per day
If yes, for how long have you smoked?
Do you consume other tobacco products?

YesNo
If yes, what type of other tobacco products?
Have you ever had a blood transfusion?

YesNo
If yes, please give approximate dates

MonthDayYear
Date
Please tell us of any serious illnesses, injuries, the approximate dates and outcomes:
Occupational Concerns: Please check any of the following your work exposes you to:

StressHazardous SubstancesHeavy LiftingOther
Your Occupation
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Signature

Clear
Date

MonthDayYear
Date
Reviewed By
Date

MonthDayYear
Date
GASTROINTESTINAL QUESTIONNAIRE
Do you have reflux/heartburn symptoms (pain in middle of lower chest that moves up when lying down)?

YesNo
If yes, how often?

1 per monthEvery 2 weeks1 per week3 per weekType option 5
Do you ever have right upper abdominal pain?

YesNo
If yes, how often?

Every 6 monthsEvery 3-4 monthsEvery month2 per monthType option 5
Do you suffer from chronic constipation?

YesNo
Do you suffer from chronic diarrhea?

YesNo
Do you suffer from chronic headaches?

YesNo
If yes, how often?

Every 6 monthsEvery 3-4 monthsEvery month2 per monthEvery week
Do you ever wake up coughing in the middle of the night?

YesNo
Do you suffer from bloating, or do you get full quickly when eating?

YesNo
Please list your current GI medications
How many years have you suffered from GI/stomach problems?

20 yrs15 yrs10 yrs5 yrs3 yrs1 yr6 mo
How often, if ever, do your symptoms recur in a year?

2 times4 times6 times8 timesToo many to count
Have you ever had your gall bladder removed?

YesNo
If yes, when?
Have you had reflux/heartburn surgery?

YesNo
If yes, when?
Have you ever been told you have irritable bowel disease?

YesNo
Have you ever seen a GI specialist?

YesNo
If yes, name of physician?
What tests did they obtain (i.e. colonoscopy, EGD, barium enema, barium swallow) and when?
Have you, or has anyone in your home, ever had a fever blister/cold sore?

YesNo
Have you ever had mono?

YesNo
Describe any other chronic medical conditions that you have:
Name
Date

MonthDayYear
Date
D.O.B
Pharmacy Name/Number
Please list all allergies including: Medications, Materials, Food, and Environmental
Name
DATE

MonthDayYear
Date
D.O.B
Pharmacy Name/Number
Please list medications, dosage, frequency, reason, and prescribing doctor
Should be Empty:

New Patient Packet - Tuscaloosa Surgical Associates, P.C.

PATIENT INFORMATION

INSURANCE INFORMATION

STATEMENT OF FINANCIAL RESPONSIBILITY

HIPAA AUTHORIZATION STATEMENT

Office Policies

CONSENT TO REVIEW PHARMACY HISTORY

HEALTH HISTORY

REVIEW OF SYSTEMS

Family History

Health Habits

GASTROINTESTINAL QUESTIONNAIRE