New Patient Registration & History Form

New Patient Registration & History

PATIENT NAME:

First NameLast Name

DATE OF BIRTH:

ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

MARITAL STATUS:

SOCIAL SECURITY:

Please circle contact preference

HOME PHONE:

Please enter a valid phone number.Format: (000) 000-0000.

CELL NUMBER:

Please enter a valid phone number.Format: (000) 000-0000.

RACE:

ETHNICITY:

Emergency contact

NAME:

First NameLast Name

CELL NUMBER:

Please enter a valid phone number.Format: (000) 000-0000.

RELATIONSHIP:

REFERRING PHYSICIAN:

PRIMARY PHYSICIAN:

PHARMANCY:

LOCATION:

EMPLOYER:

WORK NUMBER:

Primary Insurance Information

PRIMARY INSURANCE:

ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

SUBSCRIBER NAME:

DOB:

RELATION TO PATIENT:

SUBSCRIBER ID:

GROUP NUMBER:

Secondary Insurance Information

SECONDARY INSURANCE:

ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

SUBSCRIBER NAME:

DOB:

RELATION TO PATIENT:

SUBSCRIBER ID:

GROUP NUMBER:

Please note it is the responsibility of the patient to obtain referrals for treatment. If you have Blue Care Network you MUST have a Global referral before evaluation with specialist.

Financial Policy / Insurance Authorization/Assignment of Benefits

I request that payment of authorized Medicare/or any third-party benefits be made to or on my behalf to Elias H. Kassab M.D. PC, for any services furnished to me by one of its providers. I authorize any holder of information about me to the
Centers for Medicare/Medicaid Services and its agents or any third-party payer any information needed to determine these benefits or the benefits payable for related services

The undersigned acknowledges that he/she has received a detailed copy of the financial, insurance authorization and assignment of benefits policy.

SIGNATURE:

DATE:

HIPAA Consent

Please indicate if there is a friend or family member to whom we are allowed to release medical information to:

NAME:

First NameLast Name

RELATIONSHIP:

NAME:

First NameLast Name

RELATIONSHIP:

You may also identify a friend or family member to whom we are specifically restricted from releasing medical information to:

NAME:

First NameLast Name

RELATIONSHIP:

The undersigned acknowledges that he/she has received a detailed copy of the notice of privacy practices.

SIGNATURE:

DATE:

Rx History Consent

I give permission for my provider to access my pharmacy benefits data electronically through RxHub.

The undersigned acknowledges that he/she has received a detailed copy of Rx history consent.

SIGNATURE:

DATE:

Permission to Communicate my Health Information Electronically

PLEASE INDICATE YOUR CHOICE TO PARTICIPATE OR NOT IN THE EXCHANGE AS PROVIDED FOR BELOW

The undersigned acknowledges that he/she has received a detailed copy of the health information exchange.

SIGNATURE:

DATE:

MEDICATION LIST *Please complete or provide a paper copy of your own list.

MEDICATION 1

MEDICATION NAME 1 (Include over the counter medication):

STRENGTH / DOSE (MG):

NUMBER OF PILLS (Per dose):

NUMBER OF TIMES (Per day):

MEDICATION 2

MEDICATION NAME 2 (Include over the counter medication):

STRENGTH / DOSE (MG):

NUMBER OF PILLS (Per dose):

NUMBER OF TIMES (Per day):

MEDICATION 3

MEDICATION NAME 3 (Include over the counter medication):

STRENGTH / DOSE (MG):

NUMBER OF PILLS (Per dose):

NUMBER OF TIMES (Per day):

MEDICATION 4

MEDICATION NAME 4 (Include over the counter medication):

STRENGTH / DOSE (MG):

NUMBER OF PILLS (Per dose):

NUMBER OF TIMES (Per day):

Past Medical History

Diabetes

High Blood Pressure

Stroke

Heart Disease / Heart Attack

High Cholesterol

Thyroid Disease

(PVD) Vascular Disease

Bleeding Disorder

Emphysema / COPD

Liver Disease

Rheumatic Fever

Asthma

Ulcers

Mental Illness

Dementia (Alzheimer’s etc.)

Seizures

Cancer

* CANCER TYPE

Cardiomyopathy

CHF Congestive Heart Failure

Atrial Fibrillation

* OTHER

ALLERGIES

DRUG / NON-DRUG ALLERGY 1:

ALLERGIC REACTION 1:

DRUG / NON-DRUG ALLERGY 2:

ALLERGIC REACTION 2:

DRUG / NON-DRUG ALLERGY 3:

ALLERGIC REACTION 3:

DRUG / NON-DRUG ALLERGY 4:

ALLERGIC REACTION 4:

CARDIAC AND VASCULAR HISTORY / PROCEDURES

PREVIOUS PROCEDURES 1:

YEAR:

PREVIOUS PROCEDURES 2:

YEAR:

PREVIOUS PROCEDURES 3:

YEAR:

PREVIOUS PROCEDURES 4:

YEAR:

FAMILY HISTORY

FATHER:

AGE:

AGE OF DEATH: