Todays Date: Primary Insurance / Financial Responsibility

PATIENT INFORMATIONINSURANCE / FINANCIAL INFORMATION

Todays’ Date: Primary Insurance / Financial Responsibility

Patient Name: □ Aetna□ Blue Cross/Blue Shield

First Name MI□ Cigna□ United Healthcare□ Tricare

□ Medicare□ Medicare Replacement□ SelfPay

Last Name□ Other:

Address: Subscriber ID# Group:

City: Subscriber’s Full Name:

State: Zipcode: Birthdate: SS#:

Social Security #: Secondary Ins (if any)

Sex □ M □ F Age _____ BirthdateSubscriber ID# Group

INSURANCE ASSIGNMENT/SELF PAY AGREEMENT

Marital Status AUTHORIZATION TO RELEASE

□ Single □ Married □ Divorced □ SeparatedI certify that I have insurance coverage with the primary

□ Widowed □ Domestic Partnerinsurance company &, if applicable, the secondary insurance

Company listed above and assign directly to William M.

Employment StatusLetson, Jr., M.D., all insurance benefits, if any, otherwise

□ Full time □ Part time □ Retired □ Otherpayable to me for services rendered. I understand I am

financially responsible for all charges whether or not paid by

Employer/Schoolinsurance. I authorize the use of my signature for all Occupation insurance submissions. I request that payment of authorized

Medicare benefits and, if applicable, Medigap benefits, be Primary Care Physician made on my behalf to William M. Letson Jr., M.D. for any Phone Number services furnished to me by that provider. If Self Pay, I

May we contact this physician?□ Yes □ Nounderstand it is my responsibility to pay for services rendered at time of visit. The above named Facility and/or Clinician How were you referred to us? May use my health care information to my insurance

company(ies) and their agent for the purpose of obtaining payment for services and determining insurance benefits or Your Primary Pharmacy Name & Phone Number: the benefits payable for related services. I understand that if

an authorization is needed from my insurance carrier, it is my responsibility to obtain such authorization.

PHONE NUMBERS

Home* ( ) Cell* ( )X

Work* ( )Signature of Patient, Parent, Guardian or Personal Rep

*You authorize us to leave appointment messages.

IN CASE OF EMERGENCY

Printed name of Patient, Parent, Guardian or Personal Rep

Name Relation

□Self □ Parent □POA/Caregiver .

Contact Number ( )- Relationship to Patient (check one)Date

PATIENT CONSENT FOR EVALUTION OR TREATMENT and CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Medical care and treatment at the offices of William M Letson Jr., M.D. may be provided by Physicians, Advanced Registered Nurse Practitioners (ARNP), Physicians Assistant (PA) or Medical Assistants (MA). I hereby authorize the offices of William M Letson Jr., M.D. to evaluate, diagnose, and render appropriate treatment to the patient designated below. This consent is knowingly and freely given. To the extent permitted by law. I authorize any holder of medical or other information about me to release to the Center for Medicare and Medicaid Services, my Medigap insurer, and their agents any information needed to determine these benefits or benefits for related services

I hereby give my consent for the offices of William M Letson Jr., M.D. and their Business Associate’s (such as medical billing company, collection agency, automated appointment reminder vendor, dictation services, electronic prescription vendor) to use and disclose protected health (PHI) about me to carry out treatment, payment and health care operation (TPO). (The Notice of Privacy Practices provided by the offices of William M Letson Jr., M.D. describes such uses and disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. The offices of William M. Letson Jr. M.D. reserve the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Privacy Officer, 1505 Tamiami Tr S Ste 405, Venice FL 34285.

With this consent, the offices of William M Letson Jr., M.D. may call my home, mobile or other alternative location and leave a message on voice mail, text message or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.

With this consent, the offices of William M. Letson Jr., M.D. may mail or e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment cards/letters and patient statements.

It is further understood that all information given by the patient or family member to a treating clinician is confidential and will not be released, except under special circumstances, without patient consent (or consent of legal guardian). Special circumstances include response to court orders, suspicion of abuse, or identification of threat of harm to self or others.

By signing this form, I am consenting to allow the offices of William M. Letson Jr., M.D. to use and disclose my PHI to carry out TPO. I am revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, the offices of William M. Letson Jr., M.D. may decline to provide treatment to me.

I understand and agree with all of the preceding information unless otherwise indicated. I have received the “Welcome Letter”, “Patient Rights and Responsibilities” and “Notice of Privacy Practices”.

X

Signature of Patient, Parent, Guardian or Personal RepresentativeDate

Printed name of Patient, Parent, Guardian or Personal Representative

Signature of WitnessDate

PATIENT HISTORY FORM

Note: This is a confidential record and will be kept in your chart.

Today’s Date Date of Last Physical Exam

CHIEF COMPLAINT History of Present Illness:

What is the main reason for you visit today?

When did you injury or symptoms begin?

Are you in pain? On a scale of 1-10, with 10 being the most severe, what is your level of pain?

Does anything help? or make the problem worse? □ Moving around □ Standing up □ Lying on side

□ Other

How long does the problem last?□ 30 minutes □1 hour □ always there □ Other

Is anything else occurring at the same time? If yes, please explain…

□ Nausea□ Vomiting□ Rash□ Headaches□ Other

Is the problem constant or variable? □ Dull the Sharp □ Very sharp then leaves □ Always there □ Other

Does the problem interfere with your normal functions? If yes, please explain

PAST MEDICAL & SOCIAL HISTORY

List all serious illnesses in your immediate family. (Example: diabetes, cancer, heart disease, thyroid disease, etc)

List any personal past illnesses and surgeries and when they occurred.

Are you on currently taking any Medications? (Prescription, OTC, Vitamins, Supplements? □ Yes□ No. If yes, please list on medication form provided and PLEASE BRING LIST TO EACH VISIT WITH YOU!

Are you allergic to Latex? □ Yes □ NoAre you allergic to any medications? □ Yes□ No If yes, please list:

Do you Smoke?, if so, how many packs per day? Do you drink alcohol? □ Never □ Occasionally □ Daily

Have you ever had or been treated for □HPV □Herpes □ Hepatitis A, B or C (circle) □ HIV □ MRSA □ Other

Patient Name

Account #Chart #