Patient Profile I prefer the staff refer to me as _________________________________
PATIENT INFORMATION Name:
_______________________________________ _______________________________________ City,State:_______________________________________
Date of Birth: _______________________________________ Social Security #: _______________________________________ Marital Status: [ ]Married [ ]Single [ ]Divorced
[ ]M [ ]F
[ ]Home [ ]Work [ ]Other [ ]Home [ ]Work [ ]Other
Referring Physican: Primary Physician:
[ ]Employed [ ]Retired [ ]Other
A secure message may be left at _______________________________ _________________________________________________________
Phone: ( ) Employer: _______________________________________
GUARANTOR [ ]Same as Patient
Employer: ________________________________________________ Phone: __________________________________________________ Phone: __________________________________________________ Social Security #: __________________________________________ Date of Birth: _____________________________________________
_______________________________________ City,State: _______________________________________
PRIMARY INSURANCE Insured Party:
Insured Phone: Company:
Social Security #:
Date of Birth:
[ ]Same as Patient [ ]Same as Guarantor [ ]Other
Relationship to Patient: ______________________________________
[ ]Same as Patient [ ]Same as Guarantor [ ]Other
Relationship to Patient: Social Security #: Insured ID:
Date of Birth:
Whom may we thank for referring you? ______________________________________________________________________ PATIENT AUTHORIZATION I, __________________________________, hereby authorize The Center for Plastic Surgery, P.C. to apply for benefits on my behalf for covered services rendered. I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information of this or any related claim to the insurance company(s) listed above. I also agree that it is my responsibility to obtain a referral from my primary care physician when applicable and am responsible for any and all Center for Plastic Surgery fees that exceed or that are not covered by Insurance. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by me at anytime in writing. I authorize the taking of photography for medical purposes.
Signature of Patient or Authorized Person
WE WILL NEED TO COPY YOUR INSURANCE CARDS FOR YOUR CHART THANK YOU Center for Plastic Surgery, PC
CENTER FOR PLASTIC SURGERY HEALTH QUESTIONNAIRE PATIENT NAME: ______________________________________________ DATE: _________________ DATE OF BIRTH: ______________________ AGE: ______ SEX : M Are you under the care of a physician?
HT: ______ WT: ______
If yes, please list name and address: ______________
______________________________________________________________________________________ When were you last seen by your regular physician? ___________________________________________ Have you ever had surgery?
If yes, please describe: ________________________________
______________________________________________________________________________________ Have you or any family members had any problems with anesthesia? Y
If yes, please explain?
______________________________________________________________________________________ Please list your previous hospitalizations:_____________________________________________________ Are you taking any medications?
If yes, please list __________________________________
______________________________________________________________________________________ (Please include over the counter medications such as aspirin or antihistamines) Are you allergic to any medication? Y Are you allergic to Latex? Y Do you smoke? Y Do you drink alcohol? Y Are you pregnant? Y
N N N
If yes, please list: _________________________________
If yes, how many packs per day? _____________ If yes, how much? _____________________ Are you Nursing Y N
Do you have a history of any of the following: Asthma Y N Thyroid Problems Bronchitis Y N Anemia High Blood Pressure Y N Stroke Liver Problems Y N Glaucoma Ulcers Y N Hepatitis Bleeding Problems Y N Arthritis Blood clots in the Seizures lungs or legs Y N Diabetes Cancer Y N Depression Sleep Apnea Y N MRSA/Staph Infections HIV Y N Other Medical Problems
Y Y Y Y Y Y Y Y Y Y Y
N N N N N N N N N N N
If you answered “YES” to any of the above, please explain: ______________________________________ ______________________________________________________________________________________ Do you now, or have you ever used recreational drugs? Y Have you ever had a blood transfusion?
How would you describe your present health:
If so, when was the last time? ________
Is so, when: ______________________________
_____________________________________________________________ Patient/Guardian Signature
Fair __________________ Date
PATIENT CONSENT FORM Center for Plastic Surgery 1. I acknowledge that I have been given a copy of the Practice’s “HIPAA Privacy Notice” which describes the Practice’s obligation to ensure the privacy of my health information. The HIPAA Privacy Notice also describes how the Practice may use and disclose my health information for treatment, payment and health care operations. I know that I have the right to review the Practice’s HIPA Privacy Notice prior to signing this consent, and I have had the opportunity to read the Practice’s HIPAA Privacy Notice and to ask questions about it. I understand that the Practice is required to maintain the privacy of my health information in accordance with the terms of its HIPAA Privacy Notice. 2. I further acknowledge that the Practice can change its HIPAA Privacy Notice in the future, and that I can receive a copy of the Practice’s current Privacy Notice at anytime by contacting Stanley R. Zausmer (301) 652-7700 or by checking the Practice’s website at www.cpsdocs.com. 3. I understand that I have the right to request that the Practice restrict its uses and disclosures of my health information for treatment, payment, or health care operations. If my restrictions are accepted by the Practice, these restrictions will be binding on the Practice. I also understand that the Practice is not required to agree to my requested restrictions. I do not request any restrictions on the Practice’s use and disclosure of my health information for treatment, payment or health care operations. ___________ (Initial) 4. By signing this form, I consent to the Practice’s use and disclosure of my health information for treatment, payment and health care operations. I understand that I have the right to revoke this consent at anytime in writing, but if I do, my revocation will not have an effect on any actions the Practice has already taken in reliance on this consent.
_____________________________________ Signature of patient or patient’s representative
(This form must be completed before signing) If this form is signed by a patient’s representative, please complete the following: Print the name of patient’s representative:
Describe the representative’s authority to act for the patient:
*NOTE: YOU MAY REFUSE TO SIGN THIS CONSENT* HOWEVER IF YOU DO REFUSE, THE PRACTICE MAY REFUSE TO PROVIDE YOU WITH NON-EMERGENCY CARE.