Patient Name:

How did you hear about us? -Please choose an option-Holy Family ChurchSouth BulletinFriend/ FamilyPhysicianCurrent Patient

Date of Birth: 

MaleFemale

Friend or Relative not living With You:

Medical Insurance Information:

DOB: 

I hereby authorize my insurance carrier, attorney, or any third-party payer to pay directly to Southwest Internal Medicine Specialists all charges submitted for services incurred by me. I understand I will be responsible for any and all charges not paid by my insurance company. I authorize Southwest Internal Medicine Specialists to release information concerning my medical condition to my insurance company, employer, hospital, physician or attorney for the purpose of processing a claim. I assign payment directly to the physicians at Southwest Internal Medicine Specialists which may be due from the Medicare program or any other insurance company, including supplemental insurance, which may cover in whole or part medical services which I have received. The authorization and assignment shall be valid until I notify Southwest Internal Medicine Specialists in writing of the cancellation. A photocopy of this authorization shall be valid as the original copy.

Please sign below (required)

(Witness) Please sign below (required)

Signature Date:

(WITNESS) Date:

HandednessLR

Have you ever had:

Chicken PoxNoYes

HepatitisNoYes

Scarlet FeverNoYes

TuberculosisNoYes

Rheumatic FeverNoYes

PneumoniasNoYes

PolioNoYes

Venereal DiseaseNoYes

Blood TransfusionsNoYes

Have you ever been treated for:

AsthmaNoYes

Thyroid DiseaseNoYes

EmphysemaNoYes

DiabetesNoYes

Heart AttackNoYes

AnemiaNoYes

Heart FailureNoYes

CancerNoYes

Heart MurmurNoYes

Kidney DiseaseNoYes

Abnormal HeartbeatNoYes

Kidney StoneNoYes

High Blood PressureNoYes

Ulcer DiseaseNoYes

ColitisNoYes

Gall Bladder DiseaseNoYes

Blood ClotsNoYes

ArthritisNoYes

StrokeNoYes

GoutNoYes

Epilepsy(seizures)NoYes

Abnormal CholesterolNoYes

Psychiatric DisorderNoYes

Chronic Allergies, GlaucomaNoYes

Hay FeverNoYes

Colon PolypsNoYes

Other problems not listed above:

Last Colonscopy: 

Last Stress Test: 

List any operations that you have had (include approximate age): 

Have you ever been treated with X-RAY therapy or radioactive drugs?NoYes

List any medications (and dosages) you currently are taking (include over-the-counter drugs):

Habits

Tobacco use?NoYes

If so, When?

Did you quit?NoYes

Alcohol?NoYes

Coffee, tea or cola?NoYes

Do you exercise regularly?NoYes

What kind of work do you do? 

Any toxic exposure?NoYes

What method of contraception do you use (if applicable)?

Do any of your family members have or have had:

Family History:

Age

Illness

Cancernoyes

Father:

Heart AttacksNoYes

Mother:

High blood pressureNoYes

Brothers:

StrokesNoYes

Sisters:

Thyroid diseaseNoYes

Sons:

DiabetesNoYes

Daughters:

AnemiaNoYes

Other:

Kidney diseaseNoYes

UlcersNoYes

OtherNoYes

Are you bothered with:

Skin Rashes or DiscolorationNoYes

Loss of Consciousness(Fainting)NoYes

Abnormal Lumps or GlandsNoYes

Unusual or Serious Visual ProblemsNoYes

Nausea or VomitingNoYes

Hearing, Problems, EarachesNoYes

Belly PainNoYes

HeadachesNoYes

ConstipationNoYes

Frequent ColdsNoYes

DiarrheaNoYes

HoarsenessNoYes

Bloody or Tarry StoolsNoYes

Frequent or Persistent CoughNoYes

Excessive or Constant WorryingNoYes

Feeling Lonely or DepressedNoYes

Abnormal TirednessNoYes

Inability to Sleep WellNoYes

Shortness of BreathNoYes

Mood SwingsNoYes

WheezingNoYes

Poor AppetiteNoYes

Chest PainNoYes

Difficulty SwallowingNoYes

Skipped or Irregular HeartbeatNoYes

HemorrhoidsNoYes

Ankle SwellingNoYes

Trouble UrinatingNoYes

Pain in your Legs when you walkNoYes

ArthritisNoYes

Weakness in your Arms or LegsNoYes

Morning StiffnessNoYes

Loss of Sensation (numbness)NoYes

Fever or ChillsNoYes

LightheadednessNoYes

Impotence or Other Sexual DifficultyNoYes

Night SweatsNoYes

BruisesNoYes

Weight LossNoYes

Weight GainNoYes

Please give details of any yes answers or of other symptoms not listed above

Please list any other doctors you currently see:

Female Patients - Do you have any problems with:

CrampsNoYes

Heavy BleedingNoYes

IrregularNoYes

DischargeNoYes

Painful intercourseNoYes

Last Breast Exam/Mammogram  

Your last menstrual period? 

Last Pap Smear  

Last Bone Density Scan  

Number of pregnancies and any complications  

Please write your signature in the box below(required)

Date:

HIPAA is an acronym for the Health Insurance Portability & Accountability Act of 1996, a federal law. Administrative Simplification section of this Act is of Concern to our practice and requires us to comply with
specific rules regarding:

            •      Unique Identifiers for health plans, providers, individuals and employers
            •      Healthcare Transactions & Code Sets for transmitting electronic data
            •      Privacy Regulations over disclosure and use of health information
            •      Security Regulations over protections of electronic health information

All of these rules have been developed by the Department of Health & Human Services and will become final in a staged manner.

It will be the policy of Southwest Internal Medicine Specialists to release confidential information with signed consent by home telephone, answering machine, work telephone, voicemail and cellular phones.
Whenever returning telephone calls and the answering machine picks up, it is our policy NOT to leave confidential information if there is no recorded message identifying the residence. Confidential information will NOT be left with an unauthorized person who may answer your telephone.

If you would like to have your medial information released to someone other than yourself, please complete the following:

I authorize Southwest Internal Medicine Specialists to leave medical information pertaining to my care by the following methods and will assume responsibility to notify them whenever this information changes.

Home TelephoneYesNo

Answering MachineYesNo

Work TelephoneYesNo

Voice MailYesNo

Cellular PhoneYesNo

Please List authorized persons:

Spouse/Fiancé:

Parent/Guardian:

Brother/Sister:

Son/Daughter:

Friend/Other:

Some insurance plans require referrals, or pre-authorizations for services provided at a specialist office, diagnostic center, hospital, etc. Our office does have a referral coordinator on staff to process the referrals, and pre-authorizations through the insurance for patients requiring one. However, it is the responsibility of the patient to notify the referral coordinator of any scheduled appointments they may have in order to obtain
a referral, or pre-authorization. Including but not limited to appointment scheduled with a physician or facility recommended by a physician or employee at our office. A verbal recommendation is not a referral.

Due to the ever changing contracts between the insurance companies and medical service providers we do not guarantee that a provider we recommend is in network with your insurance.

A prior notice of at least 3 business days is requested, in order to ensure enough time is given for our referral coordinator to process each request, as well as for your insurance to review the request for referral or preauthorization. Failure to provide adequate notice may result in the patient having to reschedule their appointment.

A request for referral, authorization, or pre-approval does not guarantee coverage. The insurance company may need to review the request to determine if it is medically necessary according to their guidelines. In the event that the clinical information provided does not meet their criteria for approval, the request will be denied. Should this occur you will be notified of the denial by our office, as long as we initiated that request.
Completion of a referral does not guarantee payment by the insurance. The written terms of the contract will
apply.

If an insurance plan requires a referral or pre-authorization for services rendered, and the service is provided
without approval, coverage may be denied.

I have read and agree to the above stated policy.

Please write your signature in the box below(required)

Patient’s Printed Name:

Patient’s Account:

Date:

Patient’s Acct #

September 1, 2007

Please be advised effective September 1, 2007 there will be a $20.00 lab convenience fee when using our in house lab. Due to rising overhead costs and decreasing re-imbursement, we are no longer able to provide this service free of charge. Please note this fee is not covered or billable to your insurance company. If you select not to participate with this convenience fee you will be given a lab prescription so that you may have your labs done at your nearest participating provider. This fee is in addition to any other applicable copayments.

January 1, 2008

Please be advised effective January 1, 2008 there may be a $25.00 form filing convenience fee when our Doctors have to fill our paperwork for you. Due to the time it takes for some paperwork to be filled out, we are no longer able to provide this service free of charge. Please not that this fee is not covered or billable to your insurance company.

We thank you for your understanding.

Sincerely,

M.J. Galceran,M.D.
Aparna Hernandez, M.D.

I have read and agree to the above stated policies.

Please write your signature in the box below(required)

Patient’s Printed Name:

Patient’s Acc#

Date:

In order for us to be able to continue to deliver high quality of care, it is necessary to provide a financial policy. PLEASE READ ALL INFORMATION AND ACKNOWLEDGE BY SIGNING BELOW.
1. Please present your insurance card(s) at each visit. It is your responsibility to provide us with the correct information so that we may submit to your insurance. Failure to do so may make you liable for denied claims.
2. We will collect your deductible, co-payment or payment for non-covered services, along with any patient balance due the time of your visit. We accept cash, checks, Visa, MasterCard and Discover. We cannot bill you for co-pays; they must be made at the time
of your appointment.
3. If we do not participate with your insurance, we will file your claims as a courtesy and ask that you follow-up to make sure payment is made to us in a timely manner. If we do not receive payment from them within 45 days, you will be billed for any unpaid balance,
AND 1.5% monthly interest will begin to accrue on your account. Balances are expected to be paid in full within 30 days. If payment on your account is not done in a timely manner, your account may be referred to a collection agency and reported to the credit bureau.
4. MEDICARE PATIENTS: We will submit to Medicare for all your covered services. If you have a supplemental insurance, we will also submit that for you as a courtesy. If payment is not received from your supplemental insurance within 30 days of being submitted, we will ask for the balance due. If you do not have a supplemental insurance, your portion (20% of amount allowed by Medicare) will be collected at the time of service. Each year you will be expected to pay the allowed amount of your charges until your Medicare deductible is met.
5. MEDICAID PATIENTS: We are not participating providers with Medicaid. We ask that you pay for your services at the time of your visit.
6. HMO-PPO PATIENTS: If we participate with your plan, we will submit your services to your insurance for you. Your co-payment will be collected at the time of service--no exceptions. If your plan requires you to choose a primary care physician, it is your responsibility to make sure your insurance company has the physician you are seeing in our office as your PCP. If your plan requires you to have an authorization to see a
specialist, you will need to obtain that from our office prior to seeing the specialist. 72 hours notice is required to obtain all referrals. We cannot obtain retroactive referrals. If we do not participate with your plan, we will verify your out-of-network benefits, file
your services, and we expect payment of your portion of the services at the time of your visit.
7. SELF-PAY PATIENTS: Patients without insurance coverage will be expected to pay at the time of service. If you will not be able to pay in full, you must contact our billing department prior to seeing the doctor to make payment arrangements.
8. NO SHOW OR MISSED APPOINTMENTS: We understand there may be times when you are unable to keep an appointment. 24 hours notice must be provided to prevent incurring a cancellation fee. If two appointments are missed without proper notice you will be charged a $25.00 fee for routine visits and $50.00 for physicals.

Remember, whether you do or do not have insurance, you are ultimately financially responsible for payment of your services. If you have any questions regarding our financial policy, please contact our billing department or practice administrator.

I have read and acknowledge the above financial policy of Southwest Internal Medicine Specialists.

Please write your signature in the box below(required)

Date: