Please Provide Us with As Many Contact Numbers As Possible and Circle Your Primary Contact

Name:

FIRST MI LAST

Please provide us with as many contact numbers as possible and circle your primary contact number.

Home: ( ) -

Cell: ( ) -

Work Phone: ( ) - Email Address:

Address:

STREET APT# CITY STATE ZIP

DOB: / /

Age:

Sex:

Social Security #: - -

Driver’s License #:

Emergency Contact: _ Relationship: Phone#: ( ) - Reason for visit:

Are you employed: Are you a student: Marital Status: / □  Yes
□  Yes
□  Single / □  No
□  No
□  Married / □  Full-Time
□  Full-Time
□  Divorced / □  Part-Time
□  Part-Time
□  Widowed / □  Self-Employed / □  Retired
Race: / □  American Indian or Alaskan Native
□  Asian
□  Native Hawaiian or other Pacific / □  Black or African American
□  White
□  Hispanic / □  Pacific Islander
□  Unreported
□  Other Race
Ethnicity: / □  Hispanic or Latin
□  Not Hispanic or Latin
□  Refused to Report / Language: / □  English
□  Spanish
□  Indian
□  Other

Please provide the physician who referred you to us:

( ) -

REFERRING PHYSICIAN NAME TYPE OF PROVIDER PHONE NUMBER

Preferred Pharmacy Name & Number: ( ) -

NAME/STREET LOCATION PHONE NUMBER

PRIMARY INSURANCE INFORMATION

INSURANCE COMPANY NAME / POLICY NUMBER / GROUP NUMBER
PRIMARY INSURED INSURED’S DOB
SECONDARY INSURANCE INFORMATION / INSURED’S SS# / RELATIONSHIP TO PATIENT
INSURANCE COMPANY NAME / POLICY NUMBER / GROUP NUMBER
PRIMARY INSURED INSURED’S DOB / INSURED’S SS# / RELATIONSHIP TO PATIENT

Precision Vascular Interventional and associated physicians are committed to securing the privacy of your health information. We are supplying you with a copy of our Notice of Privacy Practices. You are not required to read this notice. By initialing, you are acknowledging receipt of this notice.

I request that payment of authorized Medicare and other insurance benefits be made on my behalf to Precision Vascular Interventional for any services furnished to be by any healthcare providers associated with that group. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents or insurance company for any information needed to determine these benefits of the benefits payable for related services.

I appoint Precision Vascular & Interventional to act as my authorized representative in requesting an approval from my insurance plan regarding its denial of services or denial of payment.

Unless I request to the contrary in writing, I will receive appointment reminders on my home or cell phone answering system and/or appointment reminder cards sent by mail, whichever is the policy of the practice.

PATIENT FINANCIAL RESPONSIBILITY STATEMENT

In order to maintain our fees at the lowest possible level, it is important that we have a good understanding with our patients regarding financial responsibility. We hope that this summary will be helpful toward that end. We encourage you to discuss it with us and to ask questions.

We understand that your health coverage is provided through .

INSURANCE COMPANY

·  If you have out-of-network benefits, we will happily file claims on your behalf.

·  You must pay any co-payment and applicable deductible amounts at the time of service unless other arrangements have been made with our office.

·  The remainder of your bill will be sent to your health plan for direct payment to our office.

·  If your insurance carrier has not paid our claim within 45 days, we will expect payment from you.

·  If, by mistake your health plan remits payment to you, please send it to us along with all paperwork sent to you at the time.

·  You will remain responsible for amounts and any services that are not covered by your insurance plan.

·  Your health plan may refuse payment of a claim for some of the following reasons:

1)  This is a pre-existing illness that is not covered by your plan.

2)  You have not met your full calendar year deductible.

3)  The type of medical service required is not covered by your plan.

4)  The health plan was not in effect at the time of service.

5)  You have other insurance which must be filed first.

Please understand that the financial responsibility for medical services rests between you and your health plan. While we are pleased to be of service by filing your medical insurance for you, we are not responsible for any limitations in coverage that may be included in your plan. If your health plan denies this claim for any of these or other reasons, our office cannot be responsible for this bill. It is your responsibility as the patient to pay the denied amounts in full.

Our primary mission is to provide you with quality, cost effective, medical care. Together we are trying to adapt to the changing way that health care is financed and delivered. Again, we value you as a patient and our first priority is to provide you with the best possible care. With this housekeeping core complete, we are pleased to serve you.

Sincerely,

Precision Vascular & Interventional

I have completed this form with accurate information. I have read and understand my obligations and responsibilities. I acknowledge that I am fully responsible for supplying correct insurance information, billing information, and payment of any services not covered or approved by my insurance carrier.

SIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVE DATE

AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION

Name of Patient:

FIRST MI LAST

DOB: / / Social Security #:

I, the undersigned, authorize the release of or request access to the information specified below from:

PHYSICIAN NAME

PHYSICIAN ADDRESS

PHYSICIAN PHONE NUMBER PHYSICIAN FAX NUMBER

of the above-named patient’s medical record(s).

PATIENT INFORMATION IS NEEDED FOR:

○  Continuing Medical Care ○ Military ○ Social Security/Disability

○  Insurance ○ Personal Use ○ Legal Purposes

○  School ○ Other:

INFORMATION TO BE RELASED OR ACCESSED:

○  History & Physical / ○  Operative Reports / ○  X-Ray Reports/Images
○  Progress Notes / ○  Lab/Pathology Reports / ○  Emergency Room Record
○  Care Plan / ○  Consultation Report / ○  Face Sheet
○  EKG Reports / ○  Discharge Summary / ○  Other:

The above information may be released to: PRECISION VASCULAR AND INTERVENTIONAL

12400 COIT RD, SUITE 505 DALLAS, TX 75206

DALLAS, TEXAS 75231 PHONE: 214-382-3200 FAX: 214-382-3201

I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected. I understand that the specified information to be released may include, but is not limited to: history, diagnoses, and/or treatment of drug or alcohol abuse, mental illness, or communicable disease, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS).

I understand that treatment or payment cannot be conditioned to my signing this authorization, except in certain circumstances such as for participation in research programs or authorization of the release of testing results for pre- employment purposes. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization. I understand I may be charged retrieval/processing fee and for copies of my medical records according to Texas Hospital Licensing law.

This authorization will expire One Hundred Eighty (180) days from the date of my signature unless I revoke the authorization prior to that time or unless otherwise specified by date, event, or condition as follows:

SIGNATURE OF PATIENT OR LEGALLY AUTHORIZED REPRESENTATIVE DATE

PRINTED NAME OF PATIENT OR LEGALLY AUTHORIZED REPRESENTATIVE DATE

PATIENT NAME DATE OF BIRTH

PATIENT PORTAL ACTIVATION

Our office now has the ability to communicate with patients through an electronic Patient Portal. This portal will allow you to request appointments, view lab results, view current scheduled appointments, request medication refills, request referrals to specialists, complete medical questionnaires, view summaries of your recent visits and more. In order to activate this functionality for you personally, we MUST have an active e-mail address associated with your account.

Please list your e-mail address here: @ . We will activate your account today and you will receive an e-mail within 24-48 hours with your login information.

AUTHORIZATION TO OBTAIN PRESCRIPTION HISTORY

I authorize this office to have access to my prescription drug history. I understand the authorization allows this office to obtain my prescription history electronically from retail pharmacies.

PATIENT SIGNATURE DATE

AUTHORIZATION TO DISCLOSE MEDICAL/FINANCIAL INFORMATION

Federal privacy guidelines, HIPPAA, prevent this office from disclosing protected health information (PHI) to anyone other than the patient. By signing this form, you are allowing us to communicate with designated individuals regarding your medical and financial record with this facility.

I, the undersigned, hereby authorize Precision Vascular & Interventional to disclose PHI from my medical or financial record to the following person(s):

Name:

Relationship: Type of Information (Circle One) Medical Financial Both

Name:

Relationship: Type of Information (Circle One) Medical Financial Both

***ADDITIONAL PERSONS MAY BE LISTED ON THE OTHER SIDE IF NECESSARY. ***

This authorization is given freely with the understanding that:

I may revoke this authorization in writing at any time, but not retroactively. The facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the information I have authorized.

PATIENT SIGNATURE DATE

Acknowledgment Form

I acknowledge receipt of this Notice of Privacy Rights, which I have reviewed and give my permission to Precision Vascular & Interventional to use and disclose my health information in accordance with it.

______

Signature of Patient Signature of Patient’s Representative

______

Name of Patient (Print or Type) Relationship of Representative to patient

______

Date Date

HEALTH HISTORY

Date:

Patient Name: Date of Birth: Sex: F or M

Reason for visit: Referring Doctor:

How did you hear about us? (Circle all that apply)

Radio Google search Facebook Twitter Instagram Google+ Friend Gynecologist Primary Doc

Radio Station: Boom 94.5 97.9 The Beat KRNB105.7 K104

Past Medical History Height: Weight:

Circle all that apply
Alcoholism / Dialysis / Illicit drug use
Anemia / Eczema / Keloid formation
Arthritis / Emphysema / Kidney disease
Asthma / Epilepsy / Liver disease
Bleeding tendency / Glaucoma / Low thyroid
Blood clots / Heart attack / Lung Cancer
Blood transfusion / Heart failure / Lupus
Breast cancer / Hemorrhoids / Migraines
Bronchitis / Hepatitis A / Mitral valve prolapse
Cancer ______/ Hepatitis B or C / Pneumonia
Colon cancer / Hernia / Prostate cancer
COPD / High blood pressure / Seizure
Deep vein thrombosis DVT / High thyroid / Stroke
Depression / HIV/AIDS / Tuberculosis
Diabetes / Hives / Ulcer

Previous Hospitalizations Activity Level (Circle one)

0 = Fully active

1 = Restricted in strenuous activity, able to do light work

2 = Can walk, provide all self care, moves more than 50% while awake

3 = Limited self care, confined to bed more than 50% while awake

4 = Disabled, no self-care, completely confined to bed or chair

Social history:

Marital status: Single:

Use of alcohol: Never:

Married: Rarely:

Separated: Moderate:

Divorced: Daily:

Widowed:

Use of tobacco: Never:

Previously, but quit (year):

Current packs / day:

Use of recreational drugs: Never:

Type/Frequency:

Gynecologic History (For women with pelvic pain or fibroids)

Answer and circle all that apply

Number of pregnancies______/ Heavy menstrual periods / Frequent urination
Number of births______/ Passing clots / Constipation
Number of miscarriages______/ Spotting between periods / Anemia
Number of abortions______/ Pain with periods / Blood transfusion
Number of children______/ Pain between periods / Year of last transfusion______
Want to get pregnant / Pelvic pressure / Symptoms getting worse
Number of days per period______/ Pain during intercourse / Prior hormone treatment
Number of pads/day______/ Pain after intercourse / In menopause
Number of tampons/day______/ Back pain / Prior fibroid surgery
Date of last period______/ Duration of symptoms: / Ultrasound shows fibroids
Date of last pap smear______/ weeks months years / MRI shows fibroids

Type of fibroid surgery

What makes your symptoms better

What makes your symptoms better

Vascular History

Answer and circle all that apply

Leg Symptoms

Aching / L / R / Red spider veins / L / R / Foot pain / L / R / Leg pain while walking / L / R
Hurting / L / R / Purple veins / L / R / Cold feet / L / R / Calf cramps while walking / L / R
Swelling / L / R / Purple vein network / L / R / Hair loss on leg / L / R / Hang leg down for relief / L / R
Cramping / L / R / Flat blue-green veins / L / R / Nail loss / L / R / Sore on foot not healing / L / R
Restless / L / R / Abdominal veins / L / R / Purple spots on feet / L / R / Erectile dysfunction / Yes / No
Tired / L / R / Bulging veins / L / R / Foot pain wakes you / L / R
Heavy / L / R / Skin discoloration / L / R
Itching / L / R / Leg ulcer / L / R

Are you on your feet for long period Yes No If Yes, Why

Have you been diagnosed with vein disease Yes No If Yes, When By whom

Prior Vein Treatments Family History Methods You’ve Tried

Injections / L / R / Spider veins / Mother / Father / Sibling / Leg elevation / Cold packs
Stripping / L / R / Varicose veins / Mother / Father / Sibling / Walking / Pain meds
Ambulatory phlebectomy / L / R / Deep vein thrombosis / Mother / Father / Sibling / Exercise / Ibuprofen
Ligation / L / R / Clotting disorder / Mother / Father / Sibling / Support hose / Tylenol
Ultrasound guided injections / L / R / Skin ulcer on leg / Mother / Father / Sibling / Wraps / Aspirin
Radiofrequency closure / L / R / Warm Soaks
Laser catheter ablation / L / R
Laser for spider veins / L / R
Review of Systems / Circle all that apply
Constitutional Symptoms / Eyes / Gastrointestinal / Endocrine
Good general health / Wear glasses / Heartburn / Glandular or hormone problem
Recent weight loss / Wear contact lenses / Loss of appetite / Excessive thirst or urination
Recent weight gain / Blurred or double vision / Change in bowel movements / Heat or cold intolerance
Fever / Cataracts / Nausea or vomiting / Skin becoming dryer
Chills / Ears / Nose / Mouth / Throat / Diarrhea / Hematologic/Lymphatic
Fatigue / Hearing loss / Constipation / Slow to heal after cuts
Night Sweats / Ringing in the ears / Painful bowel movements / Bleeding or bruising tendency
Cardiovascular / Earaches / Blood in bowel movements / Anemia
Heart trouble / Drainage from ears / Abdominal pain / Past transfusion
Palpitations / Sinus problem / Neurological / Date of last transfusion
Chest pain or angina pectoris / Runny nose / Frequent or recurring headaches / Enlarged glands
Shortness of breath with walking / Nose bleeds / Light headed or dizzy / Psychiatric
Shortness of breath lying flat / Mouth sores / Convulsions or seizures / Memory loss
Swelling of feet or ankles / Bleeding gums / Numbness or tingling / Nervousness
Varicose veins / Bad breath / Tremors / Depression
Deep vein thrombosis (DVT) / Voice change / Paralysis / Confusion
Sores on feet or ankles / Sore throat / Head injury / Insomnia
Phlebitis / Swollen glands in neck / Allergic/Immunologic
Blood clots in legs / Musculoskeletal / Prior adverse reaction to:
Leg cramps when walking / Back pain / Penicillin or other antibiotics
Respiratory / Pain radiating down legs / Morphine or other narcotics
Chronic or frequent coughs / Joint pain / Lidocaine or other anesthetics
Shortness of breath / Hip pain / Aspirin or other pain remedies
Wheezing / Knee pain / Iodine
Emphysema / Shoulder pain / Betadine
Coughing up blood / Joint stiffness / Skin / Breast
Genitourinary / Joint swelling / Rash or itching
Burning or painful urination / Weakness of muscles / Change in skin color
Blood in urine / Weakness of joints / Change in hair or nails
Change in force of stream / Muscle cramps / Breast pain
Incontinence or dribbling / Muscle pain / Breast discharge
Kidney stones / Cold extremities / Breast lump
Sexual difficulty / Difficulty walking

NAME: