Laila Hirjee, M.D. P a 5617 Belmont Ave Suite 103-D Dallas, Tx 75206 Ph: 214-824-3333

Laila Hirjee, M.D. P A 5617 Belmont Ave Suite 103-D Dallas, Tx 75206 Ph: 214-824-3333 Fax: 214-824-3131

New Patient Information

** PLEASE UNDERSTAND THAT LAILA HIRJEE, M.D. WILL NOT BE ABLE TO SCHEDULE PATIENT AN APPOINTMENT UNTIL ALL INSURANCE IS VERIFIED AND COPIES OF CARDS ARE OBTAINED**

Today’s Date ______Facility Name ______Room #______

Patient’s Last Name ______First______Middle Initial_____ Home Phone______

Patient’s Address ______City______State______Zip Code______

Patient’s SSN______Sex □ Male □ Female Date of Birth______

Marital Status M D W S Pharmacy Name / Phone Number______

Current Home Health Agency or CBA Organization You Are Using______

Please List ALL Allergies to Medicine or Food______

______

Are You A DNR □ Yes □ No Do You Have A Living Will □ Yes □ No

Would you like more information regarding Advanced Directives? □ Yes □ No

INSURANCE INFORMATION

PLEASE HAVE YOUR INSURANCE CARD SO WE MAY MAKE A COPY FOR OUR RECORDS

Medicare Number______(Medicare must contain Medicare Part B Coverage)

Secondary Insurance Name______Policy ID#______Group #______

Secondary Insurance Address______Phone#______

Name of Policy Holder of Secondary Insurance______Relationship To Patient______

RESPONSIBLE FINANCIAL PARTY ( PLEASE FILL OUT COMPLETELY)

Name ______Address______

City______State______Zip Code______

Relationship ______Use as emergency contact? □ Yes or □ No

Home Number______Work Number______Cell Phone______

Power Of Attorney Name:______Phone #______

PREVIOUS PHYSICIAN INFORMATION

Current Primary Physician______Phone Number______

Address______

My Hospital Of Choice Is______

______(initial) I do hereby give my permission and consent for medical treatment by Laila Hirjee, M.D. PA

______(initial) ) I understand that I will be financially responsible for payment of services if Medicare or other insurance denies payment..

______(initial) I agree to be financially responsible for any testing or treatment ordered by the doctor that may not be considered by my insurance company to be medically necessary.

______

Signature Date

Laila Hirjee, M.D. P A 5617 Belmont Ave Suite 103-D Dallas, Tx 75206 Ph: 214-824-3333 Fax: 214-824-3131

Authorization for Release of Medical Health Information

(In compliance with HIPPA this does not authorize release of Psychotherapy Information)

I hereby authorize ______

(Entity/Person from Whom Records are Requested)

______

to disclose my individual identifiable health information as described below, which may include information concerning communicable diseases such as Human Immunodeficiency Virus (“HIV”) and Acquired Immune Deficiency Syndrome (“AIDS”), mental illness (except for psychotherapy notes), chemical or alcohol dependency, laboratory test results, medical history, treatment, or any other such related information. I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form.

I understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non-health care provider; the released information may no longer be protected by federal and state privacy regulations.

______

Patient’s Name Patient’s DOB Patient’s SSN

Date(s) of service (if known):______

Description of Information To Be Released: (check all that apply)

□ Entire Medical Record□ Prescriptions

□ Medical History, Examination, Reports□ Hospital Records Including Reports

□ Allergy Records□ Laboratory Reports

□ Consultations□ Immunizations

□ Surgical Reports□ X-ray Reports

□ Treatment or Tests□ Billing and Payment Information

□ Other (be specific):______

Description of the purpose of the use and/or disclosure:

______

______

The health information described herein shall be released to: _____Hospital; __X__ Physician; _____Insurance Company; _____ Attorney; _____Patient; _____Other (check the appropriate category)

Please Release The Information To The Following Physician:

Laila Hirjee, M.D. PA 5617 Belmont Ave Suite 103-D Dallas Texas 75206 214-824-3333 214-824-3131__

(Physician Name)(Address) (City)(State)(ZIP) (Phone)(Fax)

I understand that this authorization will expire by law in 180 days from the date of this authorization unless I otherwise specify. I desire this authorization to be in effect until ______.

(expiration event/date)

I further understand that I may revoke this authorization at any time by notifying______in writing at ______. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.

______

Signature of Patient or Patient’s RepresentativeDate

______

Printed Name of Patient’s Representative

______

Relationship to PatientLegal Authority (attach supporting documentation)

Laila Hirjee, M.D. P A 5617 Belmont Ave Suite 103-D Dallas, Tx 75206 Ph: 214-824-3333 Fax: 214-824-3131

Permission To Use And Disclose Protected Health Information

Under the Health Insurance Portability and Accountability Act of 1996, as amended, I understand that I have the right to determine whether or not I wish to have my protected health information (PHI) given out throughout the course of my treatment with Laila Hirjee, M.D. PA. The PHI listed in my medical records may include: my name, location, insurance information, a brief description of my medical condition (i.e., course of treatment, physician visits, medications, prescriptions, diagnostic testing and results, referral’s for miscellaneous specialists, Home Health Agency Information, DME paperwork, past history, etc.) I understand that I have the right to ask that such information not be given to other non-medical entities or family members or anyone other than myself. I have indicated my choice below.

□ I DO wish my information to be given when questioned to other non-medical entities, family members, or anyone pertaining to that need per my doctor’s request.

□ I DO NOT wish my information to be given to anyone.

Printed Name______

Patient Signature______Date______

Relationship if not patient______

Patient’s Date of Birth______Patient’s SS#______

Patient’s Address______

If option can only be communicated orally by patient, then show it was recorded by:

Printed Name______Phone______

Signature______Date______

Department/Title______

Laila Hirjee, M.D. P A 5617 Belmont Ave Suite 103-D Dallas, Tx 75206 Ph: 214-824-3333 Fax: 214-824-3131

DNR

Are You A DNR □ Yes □ No

Living Will

Do You Have A Living Will □ Yes □ No

Advanced Directives

Would you like more information □ Yes □ No

regarding Advanced Directives?

______

Printed Name Date

______

Signature Date

Laila Hirjee, M.D. PA

5617 Belmont Ave Suite 103 D Dallas Tx 75206

Phone 214.824.3333 Fax 214.824.3131

I acknowledge that I have received a copy of the above Laila Hirjee, M.D. P A HIPAA Notification of Privacy Practices and understand it’s contents therein.

______

Patient Name (Printed) Date

______

Patient Signature Date

5617 Belmont Ave Suite 103-D Dallas, Tx 75206 Phone: 214-824-3333 Fax: 214-824-3131

Laila Hirjee, M.D. 5 6 1 7 B e l m o n t Ave S u i t e 1 0 3 - D D a l l a s, Tx 7 5 2 0 6 P h o n e : 2 1 4 – 8 2 4 – 3 3 3 3 Fax: : 2 1 4 - 8 2 4 - 3 1 3 1

Membership & American Medical Association

Associations American College of Physicians

Texas Medical Association

Metropolitan Who’s Who Association

LakePointe Medical Center 2007 Circle of Excellence

Personal Date of Birth: October 30, 1966

Gender: Female

Marital Status: Married

Hobbies: Movies, Music and Reading

References: Excellent References Available Upon Request

Laila Hirjee, M.D. PA

5617 Belmont Ave Suite 103 D Dallas Tx 75206

Phone 214.824.3333 Fax 214.824.3131

Home Health Agency Preferred Provider

Consent Form

Please check the box that applies best for you.

If in the event that the patient needs home health

 I prefer ______home health agency if

I / family member needs home health.

 I prefer for Dr. Hirjee / Facility to send whichever home health agency

that will best match my / family members home health needs.

______

Printed Name

______

Signature Date

Laila Hirjee, M.D. P A

Medical History

PAST MEDICAL HISTORY Do you now or have YOU ever had any of the following illness,

CHECK ALL THAT APPLY

PAST SURGICAL HISTORY Please Indicate The Year of any surgeries you have had

Laila Hirjee, M.D. P A

Medication History

Please list ALL Medications you are currently taking. Even over the counter medications.

Alzheimer’s in the Elderly

By: Laila Hirjee, M.D. PA

Everyday tasks becoming a problem? Are you having trouble recalling words, concentrating, naming objects, understanding commands, performing familiar actions such as word recognition or comprehending speech? These are just some of the signs to look for. Did you know that Alzheimer’s disease is one of the most common medical diseases in the elderly today? Causing cognitive impairment and a decline in mental status, it puts a substantial financial as well as mental burden on families across our country. Although the diagnosis of Alzheimer’s disease is often missed or delayed, the diagnosis can usually be made using standardized clinical criteria. In most cases it can be diagnosed and managed in primary care settings such as in the home or Assisted Living Facilities. Alzheimer’s disease is progressive and irreversible, but prescription drug therapies for cognitive impairment and for the behavioral problems associated with dementia can help to enhance a patient’s quality of life. Psychological therapy intervention with family members can also be beneficial when indicated, as nearly half of all caregivers themselves become depressed when dealing with a family member with Alzheimer’s. New breakthrough medical treatments and pharmacological advances are being made every day to ensure that patients have the very best chances of living their lives more independently, healthier and longer than ever before. If you or someone you know thinks you may have the signs of Alzheimer’s, please make an appointment with your physician today. It could make a world of difference to the ones you love. My goal as a physician is to maintain the very best quality of life for a patient and I strive to do my best to reach that goal with every patient I meet.

Board Certified In Internal Medicine

YOUR YEARS ”

5617 Belmont Ave Suite 103-D Dallas, TX 75206 Phone: 214.824.3333 Fax: 214.824.3131