Diseases of the Ears, Nose and Throat, Inc. ________________________________________________________________________________________________________________________________

□ Timothy Nash, D.O. □ Timothy Drankwalter, D.O. □ Audiology Patient Information Name: First ___________________________Last _________________________________MI _________ Date of Birth: ______________ Age: _____ Sex: M / F Marital Status: Single / Married / Widowed / Divorced (please circle one) Social Security Number: ________________________________ Street Address: ________________________________________________________________________ City: _____________________________________________ State: ___________ Zip: _______________ Home Phone: _______________________________ Cell Phone: ________________________________ Place of Employment: _______________________________ Work Number: ______________________ Spouse: ___________________________________________________ If patient is a child, both parents’ names: __________________________________________________ Emergency Contact: ________________________ Phone: _____________ Relationship: ____________ Family Doctor: ____________________________ Referring Physician: ___________________________ Insurance Information Insurance Company: ___________________________ Subscriber Name: _________________________ If patient is not the subscriber, complete below: Subscriber’s relationship to patient: __________________ SSN: ________________ DOB: ___________ Subscriber’s place of employment: ________________________________________________________

I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION, OR ITS INTERMEDIARIES OR CARRIERS, OR MY PRIVATE INSURANCE CARRIER ANY INFORMATION NEEDED FOR THIS OR A RELATED CLAIM. I PERMIT A COPY OF THE AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL AND REQUEST PAYMENT OF MEDICAL INSURANCE BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT. I AUTHORIZE THE DOCTOR TO BILL ALL SERVICES AND ALLOW MY INSURANCE CARRIER TO ISSUE INDEMNITY PAYMENTS DIRECTLY TO THE PHYSICIAN. I UNDERSTAND THAT ANY SERVICES NOT COVERED BY INSURANCE ARE THE RESPONSIBILITY OF THE RESPONSIBLE PARTY. _______________________________________________________________________________________ SIGNATURE OF PATIENT, PERSONAL REPRESENTATIVE, PARENT OR GUARDIAN (IF PATIENT IS MINOR)

______________________ DATE

Diseases of the Ears, Nose and Throat, Inc. □ Dr. Drankwalter, D.O.

□ Dr Nash, D.O. F.O.C.O.O.

□ Audiology

Medical History Today’s Date______________________ Patient Name: _______________________________________ DOB: ____/____/_______ Age: _____ Referring Physician: ____________________________________ Reason for your visit: ___________________________________________________________________ 1) Please list ALL MEDICATIONS: (including over-the-counter) that you are currently taking: □ (see list) Name:

Dose:

Times a Day:

Reason you take it:

Preferred Pharmacy________________________ Pharmacy Phone #___________________________ 2) Allergies: Medication Allergies: ______________________________________ _____ Latex Allergy: □ Yes □ No Please list any other allergies: ___________________________________________________ 3) PREVIOUS SURGERIES: □ tonsil Other Surgeries

□ ear tubes □ ear surgery □ nasal/sinus surgery □ thyroid □ (see list) Year

Comments

4) What is/was your occupation: ____________________________________________________________ Have you been exposed to excessive noise (explain): _________________________________ 5) Social History: Do you ever drink alcohol? □ Yes □ No If yes, how often? □ Occasionally □ Weekly □ Daily Do you smoke? □ Never □ Yes (__packs/day__yrs) □ Quit __packs/day__yrs) Are you exposed to second hand smoke? □ Yes □ No Do you use any other tobacco products?_____________________________________________

Diseases of the Ears, Nose, and Throat Inc. 600 Taylor Station Rd. Gahanna, OH 43230 Phone: (614) 759-8811 Fax: (614) 759-8812 www.Diseasesent.com www.Columbusent.com

Diseases of the Ears, Nose and Throat, Inc. Patient Name_________________________________

6) Family History: □ Heart Disease □ Asthma □ Diabetes □ COPD □ Hepatitis □ Stroke □ Bleeding Problems □ High Blood Press. Please list any significant illnesses in the family: Disease Family Member

Comments

Review of Systems Review of Systems: Please check all problems that you have OR Please check "NONE" Constitutional: □ none □ fevers (how high? _____) □ chills □ loss of appetite □ hair loss □ unexplained weight (circle) GAIN/LOSS Eyes: □ none □ pain □ vision change □ double vision □ itching ENT: □ none Ear: □ pain Nose: □ pain Mouth: □ pain Throat: □ pain

□ discharge □ hearing loss □ ringing/ear noise □ dizziness □ discharge □ loss of smell □ stuffy □ discharge □ loss of taste □ cavities □ dentures □ lump □ thick mucus □ tickle □ cough □ trouble swallowing □ hoarse voice

Cardiovascular: □ none □ chest pain □ history of heart attack □ shortness of breath □ leg cramp □ irregular heart beat □ history of heart disease/coronary artery disease Respiratory: □ none □ cough □ mucus □ wheezing □ asthma □ COPD □ pneumonia □ tuberculosis □ snoring □ sleep apnea GI: □ none □ nausea □ diarrhea □ constipation □ blood in stool □ hepatitis □ vomiting Urinary:

□ none □ kidney stones □ bladder infections □ frequent urination □ difficult urination □ bloody urine □ bladder cancer □ painful urination Diseases of the Ears, Nose, and Throat Inc. 600 Taylor Station Rd. Gahanna, OH 43230 Phone: (614) 759-8811 Fax: (614) 759-8812 www.Diseasesent.com www.Columbusent.com

Diseases of the Ears, Nose and Throat, Inc. Neuro: □ none □ history of stroke □ headache □ weakness □ seizures □ vision changes □ double vision □ cataracts □ migraines Musculoskeletal: □ none □ joint pain □ joint swelling □ muscle pain □ swelling □ stiffness Skin: □ none □ rash (where? ___________________) □ lesions (where? ___________________) Psychiatric: □ none □ anxiety □ depression □ mood swings □ other___________________ Endocrine: □ none □ always cold/hot □ hot flashes □ irregular periods □ frequent sweating □ diabetes Hematologic: □ none □ easy bruising □ history of anemia □ lethargy Allergic/Immuno:

□ none □ sneezing □ itching □ runny nose □ frequent colds/infections □ history of AIDS

Please sign here: The responses above are accurate to the best of my knowledge

_____________________________________________ (signature if over 18)

______________________________ (Date)

If you are not the patient _____________________________________________ (please print your name)

______________________________ (Relationship to Patient)

PLEASE DO NOT WRITE BELOW THIS LINE

Patient:

Height: _____ft______in

Heart Rate__

Weight:____

_____bpm

REVIEWED BY __________________________________________

____lbs

BMI _

Blood Pressure:__ ___/__ ___

___

DATE______________________

Diseases of the Ears, Nose, and Throat Inc. 600 Taylor Station Rd. Gahanna, OH 43230 Phone: (614) 759-8811 Fax: (614) 759-8812 www.Diseasesent.com www.Columbusent.com

Diseases of the Ears, Nose and Throat, Inc. Otologic Surgery ● Head and Neck Surgery ● Endoscopic Sinus Surgery ● Pediatric Surgery Complete Audiologic Services ● Dizziness and Balance Therapy Otolaryngologists Timothy J. Nash, D.O. Timothy P. Drankwalter, D.O.

Audiologists Melinda L. Heater, Au.D. Audra H. Woods, Au.D.

Financial and Managed Care Policy Statement Thank you for choosing us as your health care provider. To continue offering high quality care and service, we will adhere to the following financial policy. The patient/responsible party has the responsibility to assure that the financial obligation for the health care received is fulfilled. We ask that you read and sign the Financial Policy statement prior to seeing the doctor. Patients with an insurance co-payment are expected to make payment when checking in for an appointment Patients with insurance are expected to pay any personal balance due, immediately after their insurance remits payment. If insurance does not remit payment within 45 days, the patient is responsible for payment in full. If you receive an insurance payment at your home on an outstanding bill with us, that payment must be forwarded to us immediately. Not all services are covered benefits of all insurance plans. The patient/responsible party has the responsibility of verification of coverage. The patient is responsible for the payment of unpaid deductibles, co-insurance, and non-covered services at time service is provided. Uninsured patients are expected to pay in full at the time of service. Patients are requested to provide staff with sufficient notice to complete any referral forms, precertifications or other forms required by your insurer to process payment for services. Retroactive referrals will be completed for emergency care only. The patient is responsible for acquiring a referral if required by their insurance company. The patient will be responsible for any financial penalty incurred by failure to secure the proper referral. We accept cash, personal checks and credit cards (Visa, Mastercard, Discover). Returned checks and balances older than 45 days may be subject to additional collections fees. We understand that temporary financial problems may affect timely payment. We encourage you to communicate any such problems so that we can assist in the management of your account. Thank you for your understanding and cooperation with this policy. It is our privilege to provide you with your medical care. I have read and understand the Financial Policy stated above and agree to accept full responsibility as described above. __________________________________ Responsible Party

__________________ Date

Patient name if different than Responsible Party______________________________________

Consent for Purposes of Treatment, Payment and Healthcare Operations I consent to the use or disclosure of my protected health information by Diseases of the Ears, Nose and Throat, Inc. for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Diseases of the Ears, Nose and Throat, Inc. I understand that diagnosis or treatment of me by Dr. Nash or Dr. Drankwalter may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Diseases of the Ears, Nose and Throat, Inc. is not required to agree to the restrictions that I may request. However, if Diseases of the Ears, Nose and Throat, Inc. agrees to a restriction that I request, the restriction is binding on Diseases of the Ears, Nose and Throat, Inc. and Dr. Nash and Dr. Drankwalter. I have the right to revoke this consent, in writing, at any time, except to the extent that Diseases of the Ears, Nose and Throat, Inc. has taken action in reliance on this consent. My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand I have a right to review Diseases of the Ears, Nose and Throat, Inc.’s Notice of Privacy Practices prior to signing this document. The Diseases of the Ears, Nose and Throat, Inc.’s Notice of Privacy Practices is available to me in the waiting area. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Diseases of the Ears, Nose and Throat, Inc. The Notice of Privacy Practices for Diseases of the Ears, Nose and Throat, Inc. is also provided in the waiting room. This Notice of Privacy Practices also describes my rights and the Diseases of the Ears, Nose and Throat, Inc.’s duties with respect to my protected health information. Diseases of the Ears, Nose and Throat, Inc. reserves the right to change privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by accessing the Diseases of the Ears, Nose and Throat, Inc. by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. I have read this and I do not feel it is necessary to include a complete copy of the Notice of Privacy Practices in my chart when I can review the copy in the waiting room and I can request a complete copy.

_______________________________________________________ Signature of Patient or Personal Representative _____________________________ Date

HIPPA Form Keeping Your Personal Health Information Private Home / daytime contact phone number: _____________________________________ Do we have permission to call your home?

□ YES □ NO

May we leave a message with other residents? □ YES □ NO May we leave a message at your home on your answering machine / voice mail? □ YES □ NO To whom at your resident may we talk to about you medical treatment: Name: ___________________________________ Relationship: _______________________________ Home #: ___________________ Cell #: ___________________ Other phone #: ___________________ Is this person your emergency contact also? □ YES □ NO If not, please list your emergency contact below: Name: ___________________________________ Relationship: _______________________________ Home #: ___________________ Cell #: ___________________ Other phone #: ___________________ Do we have permission to call you at work?

□ YES □ NO

Work phone #: _______________________________________________________________________ May we leave a message on your work voice mail? □ YES □ NO May we leave a message at your work requesting only that you return our call? □ YES □ NO If any of the above information changes, it is the Patient / Parent / Legal Guardian responsibility to contact our office.

Patient / Parent / Legal Guardian Signature: ________________________________________________ Date: ______________________

What to bring to your appointment:

New Patient forms (completed) Current Insurance Card Co-pay for Specialist Visit List of Current Medications Photo I.D.