-
Referring Doctor Name:
田New撞Change
Patient Name: (First, Last, Mi):
Address (Street,Apt)
PATIENT REGISTRATION FORM
Date:
PATIENT INFORMATION
Telephone-Home:
Telephone-Other:
D.○○B Sex:
SS牡
EmpIoyer Nane:
Marital Status周Married鰐seperated田Divol.Ced頴Widowed酷single
EmpIoyer Address:
EmpIoyment Status:田Fu11 Time閏partTime輔Retired鰐Not EmpIoyed
Person To Contact For Emergengy:
RESPONSIBLE PARTY FOR BILLING IF DIFFERENT THAN PATIENT
Responsible Party Name (First, Last, MI)
Patient Relationship to
Responsibility:田self融spouse鰐child田oth。,:
Responsible Party Address:
′「elephone Numbers:
EmpIoyel・ Name: TeIephone:_
INSURANCE
P.O Box:
Cardholder’s Name:
Seconda「y Insurance:
P.O. Box:
Cardholder’s Name:
DOB
DOB SS#:
ALL PROFESSIONAL SERVICES RENDERED ARE CHARGED TO THE PAT】EN’「.
NECESSARY FORMS WILL BE C OMPLE’「ED TO EXPED汀E INSURANCE
CARR肥R PAYMENTS. THE PAT肥NT IS RESPONSIBLE FOR ALL FEES
REGARDLESS IF INSURANCE COVERAGE. 1T IS CUSTOMARY TO PAY FOR
SERVICE
WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN
ADVANCE
INSURÅNC巴AUTHORIZATIONS, ASS!GNMENT AND ACKNOWLEDGMENT OF RECIPT
OF NOTICE OF PRIVACY PRACT寒CES. (PLEASE READ AND
SIGN)
I HEREBY AUTHROIZE THE PHYSIC】AN TO FURNISH INFORMATION TO
INSURANCE CARRIERS CONCERNING MY ILLNESS AND TREATMENT AND I
HEREBY ASSIGN TO T暮iE PHYSICIAN ALL PAYMENTS FOR MEDICAL
SERVICES RENDERED TO MYSELF OR DEPENDENTS. 1 1INDERSATND THAT I
AM
RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE 】 AGR挽TO PAY
ALL BALANCE DUE IN FULL W汀HrN TEN DAYS OF STATEMENT
UNLESS ARRANGEMENTS HAVE BEEN MADE IN ADVANCE.
-
Bhupendra H. Mahida, M.D., F.A.C.P Ritche C. Chiu, M.D. Pius L.
Manavalan, M.D.
InitialConsult
Welcome to NephroIogy Associates ofSW Ohio? Inc? Of鯖ce ofDr.
Mahida? Dr. Manava!an and Dr. Chiu. To he!p us meet your
healthcare need§うP!ease軸out these forms in ink and bring it with
you on your schedu!ed appointment date as wel! as alI
medications you are currently taking. This is a con鯖dential
record ofyour medicai history.
DAT宙;
Name: D.0.B
Reason being Referred (Chief
Complaint):
A!le「容ies:
History of Present I‖ness:
Past Medica看History:
Have you had any ofthe following : (Circ!e ``yes,, or短no", leave
blank ifuncertain)
Pneumonia…………Yes No
Rheumatic………….Yes No
Heart Disease………Yes No
Hives or Eczema…...Yes No
Hernia………………Yes No
Any other diseases(Please =st):
Pa§t Surgerie§:
Migraines……….,Yes No BackTrouble…
Tuberculosis‥.‥‥Yes No High orLowBP
Diabetes……,…‥Yes No Asthma….
Veneral Dz………Yes No Glaucoma….
Bronchitis………Yes No Epilepsy…
…Yes No Hepatitis……….Yes No UIcer……….Yes No
‥Yes No KidneyDisease...Yes No ThyroidDz…Yes No
…Yes No Arthrltis…. …‥Yes No Cancer………Yes No
‥.Yes No AIDsorHIV+….Yes No Anemia…….Yes No
.‥YesNo Stroke…………‥Yes No T「ansfusjons‥Yes No
Has any blood re!atives had any of the foIIowing (Circle “yes”
or “no,,) Note relationship if yes.
High BIood Pl“eSSure……Yes No
St「oke Yes No
Epl】epsy Yes No
AllergleS Yes No
Anemla Yes No
Asthma Yes No
Drug/AIchohoI P「obIem….….Yes No
Mig「anes….
Thy「oid Disease‥
UIcer‥‥
Depression‥..
High Cholesterol.
Kidney Disease‥
○○ut.…
.Yes No
..Yes No
…Yes No
For each ofthe fol!owing relatives) nOte the present age and
health ifliving or the age and cause ofdeath.
Father:
Siblings:
Children:
Social History:
Smoke:
Diet:
AIcohoI(how much)
Exercise:
P!ease list any doctors you see:
Family Doctor:
Illicit Drugs
Speciality Doctors:
Occupation:
-
Current Medication§:
R.0.S (Do you have now or have you had within the past year any
ofthe following (Plea§e Circle)
Weaknes§
Tire Easily
Weight ChangesChange in Appetite
Fever
Night sweats/hot ¶ashs
Bruise Easily
B賞urred Vision
Hearing Inpaiment
Nose B賞eeds
Frequent Co!ds
Sinus Troubles
Sore Throat
Chronic Cough
Shortness of Breath
B!oody Sputum
Chest Pain
Purple fingers of lips
SweI‖ng of hands
Di部cu!ty Breathing
Pa書pitations/FIuttering
Leg Cramps
Di鮒iculty Swallowing
Heartburn
Abdominal Cramping
Nausea
Vomiting
BIood Vomit
Diarrhea
Constipation
Rectal B!eeding
Black Tarry StooI
Dark U「ine
Frequent Urination(day) Yes No
Frequent Urination(night) Yes No
Increase in Thirst Yes No
Painful Urination Yes No
Leakage of Urine Yes No
Di珊culty Starting Urine Yes No
BIood in Urine Yes No
Lack ofSex Drive Yes No
Backaches Yes No
Joint Pain or Stiffness Yes No
SwoIlen Joints
Musc営e Cramps
S!eeplessness
Seizu res
Depression
Memo「y Loss
Dizziness
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
7初雁e besI Q/〃少#nowle暗e, the q〃跨/ions on !hejbrm “ave
beemcc”rate〈y “nswere広J ”nde購!and脇atproviding加correcJ
函ゆmaiio〃 Ca〃 beくねngero鵬!o l砂*ea脇・部高砂re坤OnSib〃砂/0 ;Ig印rm lhe
doctor’s Q卵Ce Q/a′びchanges h初ay medical
sta融・ / a応o o〃脇0′ize Jhe Aea初care坤が/O Pe函)m rhe "eCeSSaly
hea初care §erVices J "ee(1
Signature of patient
Physician’s Signature
NONONONONONONONONONONONONONONONONONONONONONONONONO
誌窪漂葦葦落盤漂霊葦蒜豊治Y 。S
NONONONONONONONO
YeS窪窪窪Y 。S
-
NephroIogy Associates of SW Ohio, Inc.
3090 McBride Court, Ste B
Hamilton, Ohio 4501 1
(513)863- 8212
HIPPA Privacy Policies
Authorization to Assign Benefits
I authorize and request that the payment ofMedicare and/or
insurance benefits
be made directly to NephroIogy Associates ofSW Ohio宣br any and
all services
PrOVided to me by NephroIogy Associates of SW Ohio. Ifmy heaIth
insuranceWiI量not allow direct payment to NephroIogy Associates of
SW Ohio or if
NephroIogy Associates of SW Ohio chooses not to accept
assignment of medica看
bene鯖ts) I agree to immediately重bIWard to NephroIogy Associates
ofSW Ohio
any and aIl health insurance payments I receive.
Signature
Authorization to Disclose Protected Health Information
glVe my Permission to discIose protected health
infomation from my health records’including financial infomation
to the following
pcople:
Name:
Relationship:
Name:
Relationship:
S i gnature :
-
NephroIogy Associates of Southwestem Ohio, ENC
FENANCIAL POLICY
We are dedicated to providing the best possible care for you,
and we want you to completely understand our
financial policies.
1. AIways bring your current health insurance card to the
o餓ce.
2. Please noti皐′ uS at time ofcheck-in of any changes in
insurance, address, Phone number, etC.
3. Payment is due at the time ofservice.
4. In an attempt to keep Administrative Costs at a minimum we
are requesting payment ofyour co pay.
5・ Please make sure prior to your visit that you have all
referrals and/or authorizations required by your
insurance company for the visit.
6. Please make sure to verify with your insurance plan as to the
participation status ofthe physician you are
Seeing. We will not deny care to any patient due to uncertainty
as to participation status of our
Physicians with your insurance plan. However, if your physician
is not part of your plan your portion
Ofthe fees will most likely be higher. Ultimate responsibility
for payment of all fees is yours.
7. Keep in mind that your insurance policy is basically a
contract between you and your insurance
Company. We wilI鮒e a獲I insurance claims for you: however) the
ultimate responsibility for
Payment is yours.
8. Not all insurance plans cover all services. In the event your
insurance plan detemines a service to be負not covered’” you will be
responsible for the complete charge. Payment is due upon receipt
ofa
statement from our o節ce.
9・ As a cour触y tO all sche勿Iedpatients, We aSk /hatyou give
adequate notice侮least 24 hours) fyou
are unable to make a scheduled呼pointment・ 7h0Se Who do not give
notice 14,ill be billedj∂r /he missed
ノ4:pOintment.
10・ I understand that I am responsible to pay for aII services
rendered? inc萱uding coIIection fees,
Attorney fees up to and including court costs in the event of
defauIt.
1 1. Retum Check Fee $30.
Printed Name of Patient
Signature of Patient
Staff Member Name
-
NephroIogy Assoc. of S.W. Ohio, Inc.
3090 McBride Court, Ste B
Hamilton, Ohio 4501 1
513-863-8212
HIPAA Privacv Policies
Our commitment here at NephroIogy Assoc. of S.W. Ohio, Inc. is
to serve our customers with
PrOfessionalism and care, being sure at all times to protect the
privacy and security of all
Protected Health Information.
During the course of serving your interests it may be necessary
to share infomation with other
healthcare providers and business associates. The following are
exanples of instances where
information may be shared:
● During treatment, We may find it necessary to acquire a
laboratory analysis.
● For payment puaposes, We may uSe the services ofa billing
servi∞.
● During healthcare operations, We may need a second
opinion.
● Public Hea皿purposes, 1aw enforcement purposes; in response to
court orders;
emergency circumstan∞S; WOrkers’compensation and other
pemissible reasons.
We here at Nephrology Associates of S.W. Ohio, Inc. are comm誼ed
to obeying all Federa], State
and Local laws and regulations regarding Privacy Practices. If
any cther uses or discIosures
Other than the ones listed above are needed, infomation will
only be released with the written
au血orization ofthe individual in question. This written
authorization may be revoked at any
time by the individual, as PrOVided by law.
Medication Historv AuthoritvAs stated in our prlVaCy PraCtices:
I understand that NephroIogy Assoc. of S.W. Ohio, Inc.
utilizes electronic hea皿record software which incorporates
ePrescribing TechnoIogy. I
understand that NephroIogy Assoc・ Of S.W・ Ohio, Inc. may ac∞SS
and use my prescription
history through ePrescribing software for purposes of providing
me appropriate treatment.
If you have any questions or concems please contact our
compliance o珊cer Meena Mahida,
513-863-8212.
I have read and understand the above Notice of Privacy
Practices血at was revised on March 1 9,
2012.
Print Name Signature
-
CANCELLATION POLICY
EFFECTIVE JULY l.2006
TO AVOID A $25.00
CHARGE
TO YOUR
ACCOUNT
A 24 HOUR NOTICE
MUST BE GIVEN
TO CANCEL AN
APPOINTMENT
-
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