NORTHERN VIRGINIA ENT ASSOCIATES
UNDER 18 YEARS OF AGE PATIENT MUST BE ACCOMPANIED BY A PARENT
PATIENT INFORMATION DATE:____/_____/_____
Name:______Sex M F
Last First Middle
Street Address:______
City, State, Zip:______
Home Phone:______Birthdate:_____/_____/_____ Age:______
Cell Phone:______Patient’s Social Security Number:______-______-______
Patient Employer: ______Employer Phone: ______
Emergency Contact: ______
If minor, responsible party:______relationship______
Email Address: ______
Primary Physician/ Referring Physician:______Phone:______
Pharmacy Name: ______Phone:______
INSURANCE INFORMATION
Policyholders Name:______Birthdate:_____/_____/_____
Home Address, if different from above:______
City, State, Zip:______
Social Security Number:______
Patient’s Relationship to Insured: Circle Child Self Spouse MotherFather Other
Insured’s Employer:______Work Phone:______
Employer Address:______
City, State, Zip:______
NORTHERN VIRGINIA ENT ASSOCIATES
Please provide us with your insurance card which we will copy for our files. If a referral is needed, please provide this as well. It is your responsibility to see that a referral is obtained.
PATIENT AUTHORIZATION
I, ______hereby authorize Northern Virginia ENT Associates to apply for benefits on my behalf for covered services rendered and request payment by BC/BS and/or Medicare or any other insurance company be made directly to Northern Virginia ENT Associates. I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claim, to the above named agent. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by either me or the above named carrierat any time in writing. NOTE: IN ALL CASES, PROFESSIONAL FEES ARE THE PATIENT’S RESPONSIBILITY. I also agree to be responsible for charges incurred and additional costs associated with enforcing this agreement, including collection costs and reasonable attorney’s fees.I authorize my insurance benefits to be paid directly to the physician and I am financially responsible for all charges. I hereby consent to the release and re-disclosure of my medical record to enable or facilitate the collection, verification or settlement of my account for any amounts due from me or any third party payer, health maintenance organization, insurer or other health benefit plan. This consent applies to LMG, PC, or any of its affiliates or agents, lenders, or any third party servicer acting for LMG, PC, or any of its affiliates.
We are unable to see minors without written consent from parent or guardian. They must be accompanied by an adult that is over the age of 18.
DIVORCED PARENTS: It is the policy of this office that the parent accompanying the child will be responsible for all bills. We will not bill the other parent.
______
Date Signature of Subscriber orPatient
NORTHERN VIRGINIA ENT ASSOCIATES
Receipt of notice of privacy practices acknowledgement
I, ______, acknowledge receiving on ______, a copy of NOVA ENT Associates Notice of privacy practices.
(Print date)
Patient Signature: ______
Authorization to Release Patient Information
I, ______, hereby authorize the physicians and staff of Nova ENT, to release any and all information pertaining to my health care, test results procedures, billing and/or accounting information to the following person(s) or agencies:
_____Spouse______Parents______Other-Sibling, Friends, Relatives _____ None
Please Specify Other______
Name______Phone #______
I further authorize the physicians and their staff to contact me for appointments/ results, etc in one or more of the following ways:
May leave a message during business hours to return call to Physicians office.
_____Home______Work_____Ans. Machine at home_____Voicemail at work
_____Cell Phone – Cell phone number ( )______-______Text ______
May Leave Type of test performed and results.
_____Answering machine at home______Voicemail at work______Cell Phone
I understand that this office will release any information to those persons whom I have determined may receive this information without separate consent. In addition, I understand that this relates to all medical as well as billing information. This will be actively enforced. If you wish to change the status of this form, you must do so in person, in writing, or in the office. A copy of the privacy notice will be given to you upon request.
______
Patient SignatureDateWitness
NORTHERN VIRGINIA ENT ASSOCIATES
Patient Questionnaire (Page 1 of 2)
Today’s Date: ______
Name: ______Date of Birth: ______
Primary Care Dr / Referring Dr: ______
The following information is confidential and will not be released to anyone without your authorization.
REASON FOR VISIT:
What is the main reason for your visit today? ______
Please fill in below, or if you have a list already made, you may give us that:
Allergies:(please list all medication allergies and those to shellfish, etc) □ None
1) ______2) ______3) ______
Medicinesyou CURRENTLY take: □ None
1) ______2) ______3) ______
4) ______5) ______6) ______
Hospitalizations/Surgeries: □ None
1) ______2) ______3) ______
List previous complications with anesthesia in Personal and/or Family history: □ None
______
FAMILY HISTORY:
Have any family members had any conditions listed below or related to Ear, Nose, or Throat? :
□ High Blood Pressure□ Stroke (CVA)□ Asthma□ Loss of Hearing at an early age
□ Heart Attack (MI)□ Diabetes Mellitus□ Seizures□ Coronary Artery Disease
□ Other: ______
SOCIAL HISTORY
Marital Status: □ Single □ Married □ Separated □ Divorced □ Widowed
Do you smoke cigarettes?□ No□ Yes□ Less then 1 pack/day□ 1-2 packs/day
□ Smoked in the past, quit ______years ago
Second Hand Smoke in home? □ No □ Yes
Do you drink alcohol?□ No□ Yes□ Prior history of abuse
What is your caffeine use:□ None□ 1-2 cups/day□ More than 3 cups/day
Do you use street drugs?□ No□ Yes
Do you have a pet?□ Cat□ Dog □ Other
Do you attend Day Care? □ N/A□ Yes□ No
Do you travel? □ N/A□ Yes□ No
MEDICAL HISTORY
Have you in the last month had any of the following problems?
If box is not checked, this indicates you do not have the symptom or condition.
Height: ______Weight: ______
(page 2 of 2)
Name: ______Date of Birth: ______
General HematologyPsychiatricNeurological/ Head
□ Fatigue □ Anemia□ Anxiety□ Dizziness
□ Fever□ Easy Bruising□ Depression□ Seizures
□ Night Sweats □ Easy Bleeding□ Mood Changes□ Head Injury/Trauma
□ Chills □ Swollen Glands□ Insomnia/ Sleep Disorder□ Chronic Headaches
□ Weight Gain□ Fainting
□ Weight LossRespiratoryGastrointestinal
□ Asthma□Reflux/GERDUrinary
□ Chronic Cough□ Nausea□ Bleeding
Skin□ Wheezing□ Vomiting □ Urinary Tract Infections
□ Ulcers□ Shortness of Breath□ Diarrhea □ Urinary Calculus
□ Rash□ Apneas□ Constipation□ Urinary Frequency
□ Itching
□ LesionsMuscular-SkeletalEndocrine
Heart□ Back Pain□ Thyroid Disorders
Eyes□ Chest Pain□ Neck Pain□ Decrease in Appetite
□ Double Vision□ High Blood Pressure□ Joint Swelling□ Increase in Appetite
□ Visual Disturbances□ Low Blood Pressure□ Muscle Weakness□ Diabetes
□ Heart Attack□ Muscular Tenderness
□ Murmur (req. antibiotics)
If you do not have any of the above, please check here:
□ I do not have any of the above symptoms or conditions.
Patient initials ______