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TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A.
R. L. “Lin” Cash, Jr, M.D., FCCP
David R. Herrmann, M.D., FCCP
James T. Siminski, M.D., FCCP
Donald L. Washington, Jr, M.D.
4375 Booth Calloway, Suite 402
North Richland Hills, Texas 76180
(817) 284-4343
(817) 590-4393 Fax
Patient Name:____________________________________
Referring Physician:_______________________________
You have been scheduled for an initial consultation or hospital follow-up appointment with _________________________ on
________________ at _________ with a check-in time of ____________. The next page of this packet is a detailed map to our
facility. Below is a list of important information to assist you in preparing for this appointment.
Please complete the enclosed packet of paperwork prior to your appointment. Be sure that all highlighted lines have a
signature. The HIPAA privacy information is available in our office for your review if you are not already familiar with its
contents.
It is very important that the doctor have any old and new chest x-rays, CT chest scans or PET scans (patient must bring the
actual films and reports) for this appointment.
Please have your referring physician fax to our office or send with you any recent office notes and lab work.
You must bring all of your current medications (actual bottles please) so a correct list can be made for your chart.
New patients should plan to be in the office for a period of two hours. Patients seen in follow-up after hospitalization should
plan approximately one hour for the appointment.
If your insurance requires a referral, please make sure your referring physician has this completed and faxed to our office
prior to your appointment.
Many of our patients have sensitive respiratory conditions. Please avoid use of scented body spray, perfume, cologne,
aftershave, or anything with a heavy scent.
As a courtesy to our patients, we file charges to your insurance but all co-payments are expected at the time of service.
If you cannot keep your appointment, please call us at 817-284-4343 as early as possible. Please help us serve you
better by keeping scheduled appointments.
We look forward to meeting you at your first office visit. If we can assist you with questions prior to your visit, please feel free to
call. You may also see our website at http://www.texaspulmonary.com for answers to questions you may have.
Sincerely,
Scheduling Secretary
TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A.
R. L. “Lin” Cash, Jr, M.D., FCCP
David R. Herrmann, M.D., FCCP
James T. Siminski, M.D., FCCP
Donald L. Washington, Jr, M.D.
4375 Booth Calloway, Suite 402
North Richland Hills, TX 76180
817-284-4343
DIRECTIONS:
Major crossroads are Booth Calloway Road and West Pipeline Road. We are on Booth Calloway and north of West Pipeline.
You can get to the office from Booth Calloway and pull into the parking lot in front of the Professional building or the new
Building. We are located in the new building to the right of the Professional Building on the right, if you are facing west. Come
in the main entrance, go to the elevators to the fourth floor. Upon exiting the elevator, proceed to the right to suite 402.
Pulmonary Questionnaire
Name____________________________________ DOB_______________ Age_______ Date _________________________
Names of physicians now treating you:____________________________________________________________________________
Symptoms:_______________________________________________________ Started:_____________________________________
Questions you would like us to answer? ____________________________________________________________________________
Surgeries____________________________________________________________________________________________________
Please list other medical problems (hypertension, diabetes, etc)_________________________________________________________
___________________________________________________________________________________________________________
When was your last TB skin test and what was the result? _____________________________________________________________
Have you been exposed to chemicals or industrial dusts? ______________________________________________________________
Medications:_________________________________________________________________________________________________
___________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Allergies:____________________________________________________________________________________________________
Occupation: _________________________________________ Last X-Ray_______________________________________________
Have you ever used tobacco? ___________ Have you quit? ___________ Alcohol____________ Other________________________
Do you have any pets at home? _____________ What kind? ____________________________________________________________
Do any of these illnesses run in your family? Asthma_______ Emphysema_______ Cancer__________
Family History: Father alive? ____________ Mother alive? __________
Brother(s) alive? _________ Sister(s) alive? ___________
Children? ____________ How many? ___________
Circle the symptoms you have currently or have had recently:
Blood in sputum Sweats Snoring Weight loss
Fever Hoarseness Cough Chest pain
Sinus drainage Heartburn or indigestion Excessive daytime sleepiness
Bleeding tendency Swelling of feet or ankles History of pneumonia
Name____________________________________ DOB_______________ Age_______ Date _________________________
Check any of the diseases that run in your family AND please note who had it:
Mother Father Sister Brother Other (explain)
COPD
Asthma
Eczema
Hay fever
Nasal polyps
Lung disease
Lung cancer
Cancer (list type)
Breast cancer
Colon cancer
Skin melanoma
Pancreatic cancer
Heart disease
Coronary artery disease
High blood pressure
Stroke
High cholesterol
Diabetes
Dementia/Alzheimer’s
Blood clot to lungs
Blood clot to leg veins
TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A.
Advanced Practice Provider Consent
This facility has on staff advanced practice providers to assist in the delivery of pulmonary care.
These advanced practice providers are not physicians. They have received advanced education and training in
the provision of health care. Each can diagnose, treat, and monitor common acute and chronic diseases as well
as provide health maintenance care.
I have read the above and hereby consent to the services of an advanced practice provider for my health care
needs.
I understand that at any time I can refuse to see the advanced practice provider and request to see a physician.
Name Date
Signature
PATIENT REGISTRATION FORM Date:_______________________________
Patient Name Birth Date Sex SSN
Last First Middle
Are you currently residing in a skilled nursing facility? Yes No If yes, name of facility
Home Address
Street City State Zip+4
Home Phone Cell Phone Work Phone
Preferred contact method for reminders (select one or more):
Text (cell phone above) Voice message (circle preferred number above) Email (below) Do Not Contact
Email address I decline access to the portal
Patient Employer Employer Phone
Employer Address
Street City State Zip+4
Marital Status Religious Preference Patient Language
Ethnicity Latino/Hispanic Other Decline to Answer
Race American Indian or Alaskan Native Asian Asian Pacific American Black/African American
Caucasian (White) Hispanic More Than One Race Native American Native Hawaiian
Other Race Pacific Islander Subcontinent Asian American Unknown Decline to Answer
Spouse’s Name Spouse’s Employer
Spouse’s Work Phone Address
Referred By Phone Fax
Address
Street City State Zip+4
Primary Care Physician Phone Fax
Address
Street City State Zip+4
List other physicians you are currently seeing
Notify in case of emergency (Do not list anyone who lives with you)
Name Phone Relationship
Address
Street City State Zip+4
Have you signed a: Living Will: Yes No DNR (Do Not Resuscitate): Yes No (Please provide a copy)
Durable Power of Attorney: Yes No Date signed:_________________ (Please provide a copy)
Pharmacy Phone
Are you currently using a DME (Durable Medical Equipment) Company? Yes No
If yes, which one?
If no, who does your insurance company require you to use?
Who does your insurance company require you to use for: Lab X-ray
Is this a work-related illness/injury? Yes No Date of illness/injury Date last worked
Cause of accident, if any
I hereby authorize release of my medical records from_______________________________________________________to Texas
Pulmonary & Critical Care Consultants, PA.
Signature of Patient or Responsible Party Date
FINANCIAL POLICY
PRIMARY INSURANCE POLICY:
Insurance Co. ID No. Group No.
Name of Insured Insured’s DOB Ins Start Date
Relationship to Patient SSN Sex
Claims Mailing Address Co-pay
Phone No.
SECONDARY INSURANCE POLICY:
Insurance Co. ID No. Group No.
Name of Insured Insured’s DOB Ins Start Date
Relationship to Patient SSN Sex
Claims Mailing Address Co-pay
Phone No.
Responsible Party Name Phone Relationship
Address
Street City State Zip+4
Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy,
which we require you read and sign prior to any treatment. All patients must complete our Information and Insurance Form before
seeing the doctor. Full payment or copayment (if applicable) is due at the time of service. We accept cash, check, Visa, MasterCard,
Discover or American Express.
Regarding Insurance We cannot bill your insurance company unless you give us your insurance information. If we are nonparticipating with your insurance,
and they have not paid the balance within 90 days, the balance will be transferred to you. Please be aware that some, and perhaps all,
of the services provided may be non-covered services and/or not considered reasonable and necessary under the Medicare Program
and/or other medical insurance. These charges will be your responsibility. Our office makes every effort to obtain referral authorizations
from the Primary Care offices for patients on HMOs. Should we not be able to obtain a referral, charges will be your responsibility.
Out of Network Billing The physicians may not be participating physicians with your insurance plan, and if not, benefits may be reduced as such. You will be
responsible for any unpaid charges and/or balances. Our practice is committed to providing the best treatment for our patients and we
charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s (excluding
Medicare) arbitrary determination of usual and customary rates.
Missed Appointments Unless canceled at least 24 hours in advance, our policy is to charge for missed office and oximetry appointments at the rate of $25.00
and a separate charge for sleep testing at the rate of $200.00. Please help us serve you better by keeping scheduled appointments.
Signature of Patient or Responsible Party Date
Research Consent I give permission for clinical and physiologic data from my medical records to be used for educational and research purposes. I
understand that my identity and contact information (name, SS#, birth date, address, etc.) will never be attached to or processed with
such data.
Signature of Patient or Responsible Party Date
Appointment of Authorized Representative
Identifying Information
Patient’s name
Member’s name
Member’s address
Member’s plan identification #
Provider’s plan identification #
Service not paid / not authorized by plan
Date(s) of service
Appointment. I, , appoint Texas Pulmonary & Critical Care
Consultants, P.A. and/or Sleep Consultants, Inc. to act as my authorized representative in
requesting an appeal from in the event of denial of
services/denial of payment.
Directed payment. I agree that if the payment denial is overturned on appeal, the plan’s payment
should be paid directly to my authorized representative, and direct the plan to do so in that
event.
Member’s signature ____________________________ Date
Texas Pulmonary & Critical Care Consultants, P.A.
Sleep Consultants, Inc.
Acknowledgment of Review of
Notice of Privacy Practices
I have reviewed this office’s Notice of Privacy Practices, which explains how my medical
information will be used and disclosed. I understand that I am entitled to receive a copy of this
document.
__________________________________________
Signature of Patient or Personal Representative
__________________________________________
Date
__________________________________________
Name of Patient or Personal Representative
__________________________________________
Description of Personal Representative’s Authority
Texas Pulmonary & Critical Care Consultants, PA
Consent to release Protected Health Information (PHI)
I understand that in order to disclose my PHI, Texas Pulmonary & Critical Care Consultants, PA, must have my consent, therefore I
authorize Texas Pulmonary & Critical Care Consultants, PA to disclose my PHI as described in the provided forms to the recipients
listed below:
Description of the information to be disclosed (check all that apply)
☐All Procedures ☐Test Results ☐Appointments ☐Other ☐Surgeries ☐Billing/Account information
Name(s) of the person(s) authorized to obtain the above-mentioned information. (e.g. physician other than your referring doctor,
family members and other specified person/persons)
Name:____________________________________Relationship:_______________________________
Name:____________________________________Relationship:_______________________________
Contact Information:
I authorize Texas Pulmonary & Critical Care Consultants, PA to contact me at the following number with results or questions:
Home_____________________ Cell______________________ Work_______________________
May we leave a detailed message on your answering machine or voicemail?
Yes☐ No☐ Failure to check one of these boxes may delay results
By Patient: (print and sign)_________________________________________________________Date:_______________________
Or Patient’s Representative (print name, sign and describe authority)
__________________________________________________________________Date:___________________
Authorization expires one year from signature date.
In signing this HIPAA Patient Acknowledgement form, you acknowledge and authorize, that you hold harmless this Healthcare
Facility, its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring from
this authorization. I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law;
that this authorization remains effective until this Healthcare Facility is in actual receipt of a signed revocation or until the records
retention period required under federal and state law has expired and the records have been destroyed; that I have the right to revoke
this authorization at any time, provided I do so in writing; that I have been given the opportunity to ask questions; that I have received
a copy of the signed authorization; that I may inspect a copy of my PHI to be used or disclosed under this authorization; that this
Healthcare Facility has not conditioned provision of services to or treatment of me upon receipt of this signed authorization; and that I
may refuse to sign this authorization. A copy of this signed, dated Authorization shall be as effective as the original.
A copy of our Notice of Privacy Practices will be provided at your request.