Patient Information Record

PATIENT INFORMATION RECORD

Name: ______Date of Birth: ______Male/Female

FirstMiddleLast

Marital Status: ______Social Security # [SS]xxx-xx-______Driver’s Lic: ______

Mailing Address: ______City, State, Zip: ______

Phone: Home ______Work: ______Cell: ______

Employer: ______Student: Yes/No

Spouse/Guardian Name: ______Spouse/Guardian DOB: ______

Spouse/Guardian SS#______Phone #: ______

Name of Family member who has been a Patient/Referring Physician: ______

POLICY HOLDER INFORMATION:

Name of Insured: ______

Address: ______City, State, Zip: ______

Phone: Home ______Work: ______

Relationship to Patient: ______SS# ______DOB: ______

Employer Name & Address: ______

Primary Insurance: ______Policy#/ID#: ______Group#: ______

Secondary Insurance: ______Policy #/ID#: ______Group#: ______

I certify that the above information is correct to the best of my knowledge.

Signature: ______Date: ______

ASSIGMENT AUTHORIZATION/OFFICE FEE POLICY

I request that any payment of authorized insurance benefit, be made on my behalf to Prem Menon MD & or Vimla Menon MD for services furnished to me by these providers. I authorize Drs Prem Menon & Vimla Menon to release information to my Insurance carriers as needed to determine the benefits payable for related services. I understand that I am financially responsible for all charges (co-payment/ co-insurance/ unmet deductibles) at all times.

Date: ______Signature of Patient or Responsible Person: ______

Responsible Person’s Relationship to Patient: ______

Emergency Contact Phone #: ______

Name: ______Relationship: ______

Name of other person(s) authorized to sign/receive information regarding this Patient’s medical treatment

______

AAICAsthma, Allergy & Immunology Center

PREM MENON, M.D. VIMLA MENON, M.D.

Diplomates, American Board of Allergy and Immunology

Clinical and Diagnostic Immunology

Authorization for the use of Protected Health Information (PHI)

As required by the Health Information Portability and Accountability Act of 1996, The Asthma, Allergy & Immunology Center (AAIC) may not use or disclose your protected health information (PHI), except as provided in our Privacy/Disclosure Notice without your authorization. Your signature on this form indicates that you are authorizing the uses and disclosures of PHI described herein. You may revoke this authorization at any time by signing and dating a revocation of Authorization for use of PHI form.

I, ______(print name) hereby acknowledge that I have read and understand the Privacy/Disclosure Notice provided by AAIC and hereby agree to the use, and disclosure of protected health information that pertains to me.

OR

I, ______(print name) hereby acknowledge that I have read the nondisclosure notice. I understand I can request that AAIC not disclose my PHI related to a specific service to my Health Plan. I understand there are limitations to my right for nondisclosure. I have been provided with the explanation of the limitations and I understand them.

______

Patient/ Legal Guardian SignatureDate

Legal guardian’s relationship to patient: ______

______

WitnessDate

AAICAsthma, Allergy & Immunology Center

PREM MENON, M.D. VIMLA MENON, M.D.

Diplomates, American Board of Allergy and Immunology

Clinical and Diagnostic Immunology

ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize direct payment of medical benefits to Dr. Prem Menon or Dr. Vimla Menon for all services rendered by him/her in person or under his/her supervision.

I understand that I will be financially responsible for any balance due that is not covered by my insurance company, whether it be applied to my deductible, co-insurance, co-payment of my insurance carrier determines that the service(s) rendered are a non-covered benefit, coverage terminated or any other valid reasons. I also understand that when my insurance coverage was verified, they did not guarantee coverage or payment.

Patient Name: ______

Patient/Parent/Legal Guardian: ______

Witness: ______Date: ______

Revised 6/30/15

AAICAsthma, Allergy & Immunology Center

Authorization For Release of Medical Records

Patient’s Name: ______DOB: ______

FirstMiddleLast

Select I or II below:

1. I authorize Dr. Menon to release my records to: ______

Physician’s Full Name

______

Street AddressCityStateZip Code

1. I authorize Dr. ______to release my records to: (check one box below)

 Prem Menon, MDVimla Menon, MD

5217 Flanders Drive5217 Flanders Drive

Baton Rouge, LA 70808Baton Rouge, LA 70808

Records should include the following sections: ______

(specify what part(s) of your records you would like sent/received (i.e. labs, progress notes, tests, all…)

for the period of: (specify time frame of records)______

This authorization includes the release of detailed medical information (including, but not limited to), doctor notes, hospital records, nurses notes, therapists notes, x-ray reports, lab test reports (including but not limited to) HIV related condition, drug/alcohol abuse and/or psychiatric or psychological diagnosis. This release also authorizes the release of any and all medical records received from any other healthcare facility or provider unless otherwise specified above.

Any doctor, nurse, administrator, librarian and/or authorized staff member to whom this authorization is presented, is hereby released from all legal liability or responsibility for release of such records and/or information, because this document is a written authorization for release of medical information pursuant to LA R. S. 13:3734 (E), whereby the undersigned, the patient or patient representative, waives all limitations and restrictions on disclosure, dissemination and discussion of such records, and/or information. Once this information is released, it will no longer be protected by the federal privacy law.

I understand that I am under no obligation to sign this authorization. I further understand that my ability to obtain treatment will not depend in any way on, whether or not, I sign this authorization.

I, the patient or patient’s representative, hereby agrees that a photo static copy of this authorization may serve as an original and that this authorization shall be valid and effective for one year from the above written date, unless it is revoked by me in writing.

______

Patient’s/Parent’s or Guardian’s signatureDate

______

Witness of above signatureDate

Revocation section: ______

Primary and Secondary Insurance Information

Name: ______DOB:______Acct #: ______

Date / 1st Insurance / 2nd Insurance / Signature of Responsible Party

Revised 6/30/2015

AAICAsthma, Allergy & Immunology Center

CONSENT FOR DIAGNOSTIC PROCEDURES AND TREATMENT ACKNOWLEDGEMENT

I authorize and direct Prem K. Menon M.D./ Vimla Menon M.D. or assistants of his/her choice to perform upon:

______Patient’s name DOB:

The following diagnostic procedure or procedures will be done only if the Doctor deems it medically necessary.

Allergy skin testing with inhalant/food extracts or drugs/stinging insect venom.

In general terms, the nature and purpose of this diagnostic procedure is to inject small quantities of the extracts into the skin, in order to produce a localized wheal (swelling) and flare (redness) reaction to determine your sensitivity (allergy) to any of the injected material.

Allergen Immunotherapy (allergy shots) involve injections of serial and increasing concentrations of special extracts (serum). The extracts are prepared with the allergens (e.g. dust, mold spores, pollens or venoms) that a person is found to be allergic to. The dose and concentration of the extract is gradually increased based on his/her ability to tolerate the injections without developing a localized or generalized systemic reaction.

Some risks known to be associated with skin testing and allergy shots are:

Syncope (fainting); hives (welts); skin swelling; generalized red skin; wheezing; loss of limb function, acute exacerbation (made worse) or pre-existing conditions such as heart disease, hypertension, epilepsy, stroke, asthma, etc.; shock (collapse); anaphylaxis (sudden severe generalized allergic reaction); seizures; heart attack; stroke and even death.

I hereby authorize and direct Prem K. Menon M.D./ Vimla Menon M.D., or their assistants to provide such additional services as they may deem reasonable and necessary including, but not limited to, the treatment of severe allergic reaction in a hospital emergency room, using services of the X-ray department, laboratories, or hospitalization and I hereby consent thereto.

Follow up appointments are essential for continued patient care. During these visits, your response to medication and/or allergy shots, laboratory tests, x-ray or CT scan results are discussed at length and additional recommendations are made. Need for referral to other specialists, if necessary will also be considered. The Physicians and AAIC staff will not be responsible for the risks involved to the patient due to noncomplianceof treatment, missed appointments, and or by not obtaining the tests or procedures previously ordered.

I understand that it is my responsibility to enquire or call to get the results of my laboratory tests, x-rays, or CT scans that are not performed at Drs. Prem Menon/Vimla Menon’s office.

Drs. Prem K. Menon and Vimla Menon are consultants in Asthma, Allergy and Immunology.

ALL PATIENTS UNDER THEIR CARE ARE EXPECTED TO HAVE THEIR OWN PRIMARY CARE (Family physician, internist, or pediatrician) PHYSICIANS. In the event that you or your child requires Emergency Room care or hospitalization, you should contact your primary care physician. If your physician so desires, he or she may consult Dr. Menon.

I understand that this consent must be signed in order for Dr. Prem Menon or Dr. Vimla Menon to examine, evaluate and treat me (perform skin tests, lung function tests ,order x-rays, blood tests and prescribe medications).

I hereby state that I have read and understood this consent. This consent form is valid until revoked by me in writing.

______Signature of Patient DOB Date Time

______Signature of relative or representative (when required)

______

Witness

______

Physician

Revised June 30, 2015

5217 Flanders Drive ● Baton Rouge, LA 70808 ● (225) 766-6931 ● 1-800-DRMENON● FAX: (225) 766-9413