New Patient Information

Patient Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Last Four Digits of SS No.
Marital Status
Race
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Pharmacy Name
Pharmacy Phone
Please enter a valid phone number.
Employer's Name
Work Phone
Please enter a valid phone number.
Employment Status

SPOUSE INFORMATION
Name of Spouse

First NameLast Name
Date of Birth

MonthDayYear
Date
Spouse Phone
Spouse Employer's Name
Spouse Work Phone

RESPONSIBLE PARTY IF OTHER THAN PATIENT
Responsible Party Relationship To Patient

Self (if self, please skip to the next section)SpouseParentOther
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Home Phone
Work Phone

PRIMARY PHYSICIAN
Primary Physician

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

REFERRING PHYSICIAN
Referring Physician

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

EMERGENCY CONTACT
Emergency Contact/Next of Kin

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ADVANCED DIRECTIVE FOR HEALTH CARE/LIFE SUPPORT
Person you have designated to make health care decisions if you are unable to make them for yourself.
Name

First NameLast Name
Phone Number

FINANCIAL RESPONSIBILITY
1. I request that payment under any medical insurance programs (Medicare, BC/BS, or any commercial insurance carrier) can be made payable to PULMONARY MEDICINE ASSOCIATES for any services provided to me by its associated physicians.

2. I also authorize the release of any medical information necessary to process claims on my behalf and the use of a copy of this authorization in place of the original.

3. I understand that I am financially responsible for any amount not paid by the insurance.
Date

MonthDayYear
Date
Signature

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RECEIPT OF NOTICE OF PRIVACY PRACTICE FORM
RECEIPT OF NOTICE OF PRIVACY PRACTICE FORM
I hereby acknowledge receipt of the physician's Note of Privacy Practices. The Notice of Privacy Practice provides detailed information about how the practice may use and disclose my confidential information.

I understand that the physician has reserved the right to change the privacy practices described in the notice. I also understand that a copy of any revised notice will be provided to me or made available.

CONSENT FOR TREATMENT AND/OR TESTING
CONSENT FOR TREATMENT AND/OR TESTING
CONSENT TO HOSPITAL ADMISSION AND/OR MEDICAL TREATMENT

I am entering Pulmonary Medicine Associates, Advocate Condell, Ascension St. Francis for the purpose of in/outpatient diagnosis and/or medical and/or surgical treatment and do hereby consent to such routine diagnostic procedures and hospital care as may be deemed necessary by my attending physician and assistants or designees.

I am aware that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made to me as to the result of diagnosis, treatments, medications, tests, or examination at Pulmonary Medicine Associates, Advocate Condell, Ascension St. Francis.

I understand that the physician who provides professional services to me (such as attending physician, anesthesia, radiology, etc) are independent contractors who will be providing specialized services on my behalf and as such will be my employees or agents. I acknowledge that I may receive a separate bill from these providers. This form has been fully explained to me and I am satisfied that I understand all the above statements and that I have the right to refuse treatment.
CONSENT TO RELEASE OF INFORMATION

The undersigned hereby authorizes Pulmonary Medicine Associates to discuss and release information from my medical records for continuity of care. Pulmonary Medicine Associates may discuss and release copies of my medical records with/to employer groups, review organizations, insurance companies, ambulance services, and their agents, government agencies, or other third-party payers and their agents. For the purpose of payment or other health care operations as outlined in our Notice of Privacy Practices. Information concerning medical care, advice, treatment, supplies, or other information may also be released if necessary for determining eligibility and available benefits and obtaining payment on my behalf for the health care services provided to me. I further agree that the hospital has and shall have no liability of any sort by reason of such release of information.

I understand that photographs, videotapes, digital or other images may be records to document my care, and I consent to this. I understand that Pulmonary Medicine Associates will retain the ownership rights to these images, but that I will be allowed access to view them or obtain copies.

I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law. Images that identify me may be used only for purposes of treatment, payment or health care operations and will not be released and/or used outside the organization for any other purpose unless authorized by my legal representative or myself.
ASSIGNMENT OF INSURANCE BENEFITS AND PAYMENT GUARANTEE

I hereby represent and agree as follows:

If I am currently uninsured, or if my medical insurance coverage is not sufficient to satisfy the Pulmonary Medicine Associates and it's physician's charges in full, I acknowledge that the resulting balance is not covered by the assignment below, and I will be fully responsible for the payment of the resulting balance due as consideration for hospital and medical services rendered.

I further agree to pay the established rates of Pulmonary Medicine Associates and its physicians for all services, facilities and supplies provided, plus any and all costs incurred in or related to the collection fo such charges including but not limited to reasonable collection agency fees, reasonable attorney's fees and costs of suit.

NEW PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION
NEW PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION

FOR TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS
I understand that as part of my healthcare, Pulmonary Medicine Associates, SC originates and maintains paper and/or electronic records describing my health, history, symptoms, examination, test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:
- A basis for planning my care
- A means of communication among the many health professionals who contribute to my care
- A source of information for applying my diagnosis and surgical information to my bill
- A means by which a third-party payer can verify that services billed are provided
I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
- The right to review the notice before signing this consent
- The right to object to the use of my health information for directory purposes
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations
I understand that Pulmonary Medicine Associates, SC is not required to agree to the restriction requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code Of Federal Regulations.

I further understand that Pulmonary Medicine Associates, SC reserves the right to change its notice and practices before implementation, in accordance with Section 164.520 of the Code Of Federal Regulations. Should Pulmonary Medicine Associates, SC change their notice, they will send a copy of any revised notice to the address I've provided whether by US mail or email.

I understand that as part of this organization's treatment, payment or health care operations, it may become necessary to disclose my protected information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.
I wish to have the following restrictions to the use or disclosure of my health information:
I fully understand and accept/decline the terms of this consent.
NAME*

First NameLast Name
SIGNATURE*

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DATE*

MonthDayYear
Date

CANCELLATION AND NO SHOW POLICY
CANCELLATION AND NO SHOW POLICY
Dear Patient,

We strive to meet and exceed the expectations of all our patients and we are dedicated to rendering excellent medical care to you and the rest of our patients. In order to meet your needs we are implementing a cancellation and no-show policy. This policy enables us to better utilize available appointments for our patients.

We understand that situations arise in which you must cancel your appointment. It is therefore requested that if you must cancel your appointment you provide at a minimum 48 hours' notice. Time is specifically reserved for you on the physician's schedule when you make your appointment. When sufficient notice is not given to cancel or reschedule your appointment, it does not give us enough time to contact another patient who could come to the clinic during your assigned time. This results in patients not getting the care they need, when they need it.

As a courtesy, we contact you the day before your appointment to remind you of your appointment date and time.

Office appointments which are cancelled with less than 48 hours notification may be subject to a $50.00 cancellation fee. Cancellation less than 48 hours will be reviewed on a case by case basis.

Patients who do not show up for their appointment without a call to cancel an office appointment will be considered a NO SHOW. Patients who no-show two (2) or more times in a 12 month period, may be dismissed from the practice and denied any future appointments. Patient may also be subject to a $50.00 fee for not showing to an appointment.

NOTE: THESE FEES ARE NOT COVERED BY YOUR INSURANCE COMPANY AND ARE THE SOLE RESPONSIBILITY OF THE PATIENT AND MUST BE PAID IN FULL BEFORE THE NEXT APPOINTMENT.

Our practice firmly believes that good physician/patient relationship is based upon understanding and good communication. Your health is important to us.

Please sign that you have read and understand this Cancellation and No Show Policy.
Patient Name*

First NameLast Name
Signature of Patient or Patient Representative**

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Date*

MonthDayYear
Date

DEPRESSION SCREENING
DEPRESSION SCREENING

Over The Last 2 Weeks, How Often Have You Been Bothered By Any Of the Following Problems?
Little interest or pleasure in doing things?*
Feeling down, depressed, or hopeless?
Total Score
Please add the numbers and enter the total here.
Should be Empty:

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Patient Information

Person you have designated to make health care decisions if you are unable to make them for yourself.

RECEIPT OF NOTICE OF PRIVACY PRACTICE FORM

CONSENT FOR TREATMENT AND/OR TESTING

NEW PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION

I fully understand and accept/decline the terms of this consent.

CANCELLATION AND NO SHOW POLICY

Please provide an updated, accurate and complete list of all your medications for each office visit.

Patient Drug/Medication Allergies & Allergic Reactions

Patient Tobacco/Alcohol/Caffeine Usage

DEPRESSION SCREENING