766 Walther Road, #300

Lawrenceville, GA 30046

770-237-3000

Information - Confidential

What is the Reason for your visit today? ________________________________________Date______________

How were you referred to our office? Internet Insurance book Friend / Relative _________________________________ Primary Care Physician

Who is your Primary Care Physician?_________________________________________________

Patient Name________________________________________________ Check appropriate box: Male Female

SSN_________________________________ Birthdate__________________________ Age: ______________________

Address____________________________________ City________________________ State________ Zip___________

Home Phone______________________________ Email Address___________________________________________

Cell Phone_________________________________ Other Phone____________________________________________

Check appropriate box: Minor Single Married Separated Divorced Widowed

Patient’s employer___________________________________________________ Work phone_____________________

Occupation______________________________________ Driver’s license #___________________________________

Spouse name_______________________ Employer________________________ Work phone____________________

Person to contact in case of emergency_______________________________________ Phone____________________

Responsible Party (if patient is a minor)

Person responsible for this account___________________________________ Relationship to patient_______________

Address___________________________________ City________________________ State_________ Zip___________

Home phone_____________________________ Driver’s license #___________________________________________

Birthdate________________________________ Social Security #___________________________________________

Employer_____________________________________________________ Work phone__________________________

Insured Party Information (policy holder)

Name of insured_________________________________________ Relationship to patient________________________

Birthdate_________________ Social Security #__________________________ Date employed____________________

Name of employer__________________________________________________ Work phone______________________

Insurance company_____________________________ ID #__________________________ Group #_______________

3915 Johns Creek Court, #100 Suwanee, GA 30024770-237-3000

766 Walther Road, #300

Lawrenceville, GA 30046

770-237-3000

Insurance co. address________________________________ City___________________ State________ Zip_________

How much is your office visit co-pay/co-insurance? _________________________ Group name ____________________

Pharmacy Information Name of your Pharmacy__________________________ Address / Location_____________________________

Phone Number _________________________________ Fax Number __________________________________

Patient Name_______________________ Birthdate_________________ Patient #_____________

Do you have additional insurance? ⃞ Yes ⃞ No If yes, complete the following:

Name of insured_________________________________________ Relationship to patient________________________

Birthdate_________________ Social Security #__________________________ Date employed____________________

Name of employer__________________________________________________ Work phone______________________

Insurance company_____________________________ ID #__________________________ Group #_______________

Insurance co. address________________________________ City___________________ State________ Zip_________

How much is your office visit co-pay/co-insurance? _________________________ Group name ____________________

Worker’s compensation information

Is this a worker’s compensation claim? □ Yes □ No If yes, complete the following:

Employer contact_____________________________________ Employer phone #_______________________________

Worker’s Comp contact ________________________________ Worker’s Comp phone #__________________________

Date of Injury _______________________ Description of Injury_____________________________________________

_________________________________________________________________________________________________

[Office Use Only] Claim #______________________ Worker’s Comp Carrier _______________________________

Worker’s Comp Carrier Address_______________________________________________________________________

_______________________________________________________________________

Procedure for Filing Claims___________________________________________________________________________

3915 Johns Creek Court, #100 Suwanee, GA 30024770-237-3000

766 Walther Road, #300

Lawrenceville, GA 30046

770-237-3000

Authorization & Release With this signature, I hereby authorize Northeast Atlanta Ear, Nose and Throat, P.C., to

release any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor. Furthermore, I understand that regardless of insurance, I am ultimately responsible for payment of fees for professional services rendered, including non-covered services. If my insurance company (ies) changes at any time, I am responsible to notify this office and provide a written copy or will be ultimately responsible for payment of professional service fees rendered at that time.

__________________________________________________________________ _______________________________________ Signature of patient (or parent or legal guardian) Date

Collection Charges In the event that any bill goes to a collection agency you agree to reimburse us the fees of

any collection agency, which may be based on a percentage at a maximum of 28% of the debt, and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collection efforts.

__________________________________________________________________ _______________________________________ Signature of patient (or parent or legal guardian Date

3915 Johns Creek Court, #100 Suwanee, GA 30024770-237-3000

Name: Birthdate: / / Date: / /

PATIENT HISTORY

Do you have… Additional for

Under age 18:

Drug Allergies? If none, please write NONE ______

Current Medications?

Surgeries and Injuries?

FAMILY HISTORY

Has anyone in your family had...

SOCIAL HISTORY

Do You…

❑ Exercise Regularly ❑ Use Alcohol ❑ Use Tobacco ❑ Use Drugs

Type: __________ Beer/Wine/Liquor Cigarettes/Cigars/Pipe/ Marijuana/Heroin/

How often:_______ How Often: Snuff/Chew Tobacco Cocaine/LSD/Crack

Signature of person filing out information _______________________________________

_____ _____

For Office Use Only

Reviewed/Updated ___/___/___;__ ___/___/___;__ ___/___/___;__ ___/___/___;__

___/___/___;__ ___/___/___;__ ___/___/___;__ ___/___/___;__ ___/___/___;__

___/___/___;__ ___/___/___;__ ___/___/___;__ ___/___/___;__ ___/___/___;__

❑ Alcoholism ❑ Dizziness/Vertigo ❑ Lung Problem ❑ Mom-Pregnancy

❑ Anemia ❑ Emphysema ❑ Mental Illness Complications

❑ Angina/Heart Attack ❑ Epilepsy or Seizures ❑ Stroke ❑ Complications at

❑ Arthritis ❑ Glaucoma ❑ Thyroid Problem Birth

❑ Asthma/Hay Fever ❑ Headaches ❑ Tinnitus/noises in ears❑ Childhood Diseases

❑ Birth Defects ❑ Hearing Loss ❑ Tuberculosis ❑ Birth Defects

❑ Bladder Disease ❑ Heart Failure ❑ Venereal Disease

❑ Bleeding Disorder ❑ High Blood Pressure ❑ Other __________

❑ Cancer: _____________ ❑ Kidney Disease ❑ Other __________

❑ Diabetes ❑ Liver Problems ❑ Other __________

❑ Alcoholism ❑ Cancer: _______ ❑ Kidney Disease ❑ Other __________

❑ Anemia ❑ Diabetes ❑ Liver Problem ❑ Other __________

❑ Angina/Heart Attack ❑ Emphysema ❑ Lung Problem ❑ Other __________

❑ Arthritis ❑ Epilepsy or Seizures ❑ Mental Illness

❑ Asthma/Hay Fever ❑ Glaucoma ❑ Stroke

❑ Birth Defects ❑ Headaches ❑ Thyroid Problem

❑ Bladder Disease ❑ Heart Failure ❑ Tuberculosis

❑ Bleeding Disorder ❑ High Blood Pressure ❑ Venereal Disease

Northeast Atlanta ENT & Allergy

Cancellation, Rescheduling, and No-Show Policy

As a courtesy we attempt to make confirmation calls 48 hours in advance of

your scheduled appointment, however you are also responsible for keeping

track of your appointment. We will attempt to leave a reminder message on

your answering machine if you have one or give the information to

whomever answers if you are not available.

Our office requests the courtesy of a 24-hour notice when you know that you

cannot keep your appointment. Unfortunately, whenever an appointment is

missed our overhead expenses continue to rise and we are unable to fill the

open time due to the lack of sufficient notice. Instead of increasing our

overall fees we have created this policy with the hope that it will encourage

patients to provide us with sufficient notice whenever an appointment cannot

be kept. For that reason, same day cancellations, reschedules, and no shows

will result in a $45.00 charge to your account.

A one-time consideration will be made for failure to show up for your

appointment or for same day cancellations and rescheduling. After that there

will be a charge of $45.00 and payment must be made before another

appointment may be scheduled.

Thank you for your understanding!

I have read the above policy and I understand that I will be charged if I

cancel or reschedule my appointment on the same date of the

appointment, or if I fail to show up for my scheduled appointments.

_________________ __________________

Print Patient Name Date of Birth

_____________________ ____________________ _________ Patient/Guarantor’s Signature Guarantor/Guardian’s Name Date

Northeast Atlanta ENT& Allergy POTENTIAL ADDITIONAL COSTS TO YOU

During your visit certain tests / procedures may need to be performed that may result in an additional charge above and beyond the office visit charge (see examples below). This may appear as a surgical procedure on your statement (Explanation of Benefits) from your insurance company. Depending on your insurance contract, you may be required to pay additional fees for deductible, co-insurance, and/or co-pay. This can only be determined after submission to your insurance company.

Examples (most common):

Endoscopy – Insertion of a small flexible or rigid lighted scope into your nose or mouth to better visualize either your nose or your throat.

Microscope – Use of a microscope to visualize the ear canal and drum.

Ear Wax Removal – Removal of impacted cerumen (earwax)

Hearing Tests – If you come back for a Hearing Aid Evaluation, and a hearing test is ordered, this is billable charge.

**************************** I have read and understand the information provided and that the procedures performed by the Northeast Atlanta Ear Nose & Throat, P.C. physician may incur additional costs with my insurer.

_________________ Patient / Parent / Guardian Signature Date

Staff Initials

If you have any questions about your bill, please call our Billing Dept at 770-237-3000

P:\Forms

NORTHEAST ATLANTA

ENT & Allergy Jeffrey Roth, M.D.

Ajaz Chaudhry, M.D.

Julie L. Zweig, M.D.

Ravi Gorav, M.D.

Matthew Carmichael, M.D.

766 Walther Road

Suite 300

Lawrenceville, GA 30046

(770) 237-3000 Phone

(770) 237-5530 Fax

3915 Johns Creek Court

Suite 100

Suwanee, GA 30024

(770) 623-1608 Phone

(678) 992-2540 Fax

Physicians Assistant

Mimi Ellis, PA-C

Angela Jones, PA-C

Doctors of Audiology

Elizabeth J. Nerren, Au.D. Katie M. Saleeby, Au.D. Sara M. Woolley, Au.D. Arlene Hicklin, Au.D.

www.northeastatlantaent.com

Authorization to Share Medical and Financial Information

Your Right to Medical Information Confidentiality

HIPAA is an acronym that stands for Health Insurance Portability and Accountability Act that was made into law in 1996. By law, if you are 18 years or older, you have the right to strict confidentiality regarding your visits to Health & Wellness Clinic. In order to release any information including the date or nature of your visit, Northeast Atlanta ENT has to have your signed consent and specific directions about what information you are consenting to be released. Without written consent, Northeast Atlanta ENT cannot release or discuss any information relating to your visit with anyone including your parents, guardians, spouse, faculty, staff, coach and other medical professionals. In addition you have the right to revoke this authorization at any time, and will be effective when Northeast Atlanta ENT receives your written revocation. A copy of this authorization will be kept in your Northeast Atlanta ENT health record. The information disclosed under this authorization might be redisclosed by a recipient and may, as a result of this disclosure, no longer be protected to the same extent as this information was protected by law while solely in the possession of Northeast Atlanta ENT.

Patient's Name (Please Print) _________________________________________________________

Date of Birth: _______________________________

In signing this authorization to release my protected health information I acknowledge that I have read and understand my rights to medical information confidentiality and authorize Northeast Atlanta ENT to discuss my health issues. I also authorize Northeast Atlanta ENT to discuss any financial information regarding my account with the following listed individuals only:

____________________________________________________________________ Name /Relationship

____________________________________________________________________ Name / Relationship

_______________________________________________________________________ Patient Signature Date

________________________________________________________________________ Northeast Atlanta ENT Staff Date

PATIENT NAME:________________________________________ DATE OF BIRTH__________CHECK ANY SYMPTOMS YOU HAVE HAD WITHIN THE LAST 24 HOURS. CHECK ONLY THOSE THAT APPLY.GENERAL GENERAL HEENT HEENTAppetite Loss Pérdida del Apetito Throat Itching Picor de Garganta

Chills Escalofrios Ear Itch Picor de Oído

Fatigue Fatiga Burning Mouth Ardor en la Boca

Fever Fiebre Lump in Throat Nudo en la Garganta

Night Sweats Sudores Nocturnos Headache Dolor de Cabeza

Unintentional Weight Loss/Gain Blurred Vision Visión Borrosa

Pérdida/Ganancia de Peso Involuntaria Excessive Tearing Lagrimeo Excesivo

SKIN PIEL Eye Pain/Puffiness Dolor/Hinchazón en los Ojos

Dryness Sequedad Visual Disturbances Alteraciones Visuales

Excessive Sweating Sudoracion Excesiva Hearing Loss

Hair Loss Pérdida de Cabello Ear Discharge

Hives Ronchas Ear Infection

Itching Picazón Ear Pain

New Lesions or changes Nuevas Lesiones o Cambios Ringing in Ears

Rash Erupción Spinning Sensation or Dizziness

Runny Nose

NECK CUELLO Nosebleeds

Neck Pain or Stiffness Dolor de Cuello o Rigidez Frequent Colds

Neck Swelling Hinchazón del Cuello Nasal Congestion

Neck Mass or Lump Masa o Bola en el Cuello Sneezing

Swollen Glands Inflamación de los Ganglios Seasonal Allergies

Sinus Pain

Respiratory RESPIRATORIO Snoring

Cough Tos Hoarseness

Difficulty Breathing Dificultad para Respirar Oral ulcers

Sputum Production Flemas (Gargajos) Constantes Sore Throat

Asthma Asma Voice Changes

COPD(Chronic Obstructive Pulmonary Disease) Dry Mucous Membranes

Enfermedad Pulmonar Obstructiva Crónica Decreased Sense of Smell

Cardiovascular CARDIOVASCULAR Facial Numbness/Tingling

Abnormal Bleeding Sangrado Anormal Choking Sensation

Cardiovascular Surgery Cirugía Cardiovascular GastrointestinalSwelling of extremities Hinchazón de las Extremidades Change in Bowel Habits

Heart Disease Enfermedad del Corazón Difficulty or Painful Swallowing

Fainting/Blacking Out Desmayo/Perder el Conocimiento Nausea or Vomiting

Difficulty Breathing when Lying Down Reflux

Dificultad para Respirar al Acostarse EndocrineMusculoskeletal MUSCULOESQUELÉTICO Thyroid Problems

Arthritis Artritis Diabetes

Joint Pain or Stiffness Dolor en las Articulaciones o Rigidez NeurologicalPhysical Disability Discapacidad Física Attention Deficit

Psychiatric PSIQUIÁTRICO Difficulty Speaking

Anxiety Ansiedad Seizures

Change in Sleep Pattern Cambios en el Patrón de Sueño Stroke

Personality Changes Cambios de Personalidad General Weakness

Pharmacy Information:

Pérdida de la Audición

Secreción del Oído

Infección del Oído

Dolor del Oído

Zumbido en los Oídos

Sensación de Girar o Mareos

Nariz que Moquea

Hemorragias Nasales

Resfriados (Gripes) Frecuentes

Congestión Nasal

Estornudos

Alergias Estacionales

Dolor en las Sinositis

Ronquidos

Ronquera

Ulceras Orales

Dolor de Garganta

Cambios en la Voz

Sequedad de las Mucosas

Disminución del Sentido del Olfato

Entumecimiento/Hormigueo Facial

Sensación de Ahogo

GASTROINTESTINALCambios en los Hábitos Intestinales

Dificultad o Dolor al Tragar

Náuseas o Vómitos

Reflujo

ENDOCRINOProblemas de la Tiroides

Diabetes

NEUROLÓGICODéficit de Atención

Dificultad para Hablar

Convulsiones

Derrame Cerebral

Debilidad GeneralTODAY'S DATE_____________ FECHA DE HOY_____________

Address: ________________________________Phone Number:______________________

Office Use Only

Wt:_________

Ht:_________

B/P:_______

TEMP:_______

P:___________

MED REFILLS:______________