Bram Wieskopf, MD
Michael G. Skardasis, M D PATIENT INFORMATION:
Date__________________ Last Name______________________________ First __________________________ M.I. _________ Address_________________________________________________________________ Apt. # _____ City _________________________________ State ____________ Zip _____________________ Social Security # _____________________________
D.O.B. __________________________
Home #: _____________________ Work#: ______________________ Cell#: ____________________ Marital Status (Please Circle) S Race __________________
M
D W
Spouse’s Name ____________________________
Ethnicity ___________________
Language ____________________
How did you hear about the practice? _____________________________________________________ Discussion of Patient’s Medical Information: (1) Please list with whom we may discuss your medical information: __________________, ________________, ___________________, (2) Leave test results on your home answering machine? Insurance Information:
NO
YES
Insurance Name & Address: ____________________________________________________________ Name of Insured: _______________________________________ Relation: _____________________ SSN of Policy Holder ____________________________________ DOB ________________________ Employer Information: Employer Name __________________________________ Occupation: _________________________ Employer Address ____________________________________________________________________ Brief Description of Daily Activities at Work _______________________________________________ Emergency Contact Information: Name: __________________________________________ Relation: __________________________
Home Phone ____________________________________ Work Phone _________________________
Preferred Pharmacy: Name ___________________________ Phone ____________________ Fax____________________ MEDICATIONS: List prescription medications being taken regularly including dosage. NAME ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________
DOSAGE ____________ ____________ ____________ ____________ ____________ ____________ ____________
FREQUENCY ____________ ____________ ____________ ____________ ____________ ____________ ____________
NON-PRESCRIPTION MEDICATIONS: List all non-prescription drugs and frequency of usage. ____________________________________________________________________ ____________________________________________________________________
ALLERGIES: List all allergies to medications, immunizations, foods, etc. MEDICATION REACTION ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ __________________________________ PERSONAL HABITS: How much of the following do you use per day? Do you have a living will?
No
Yes
(If yes, please provide a copy)
Do you have a Power of Attorney?
No
Yes
(If yes, please provide a copy)
Do you exercise regularly?
No
Yes
Times per week ____ Type_______
Do you chew tobacco?
No
Yes
Packs per week ____ No. of years ____
Do you drink alcohol?
No
Yes
Drinks per week _____
Do you now or have you ever smoked? If you have quit, how long ago?
No Yes __________
Are you exposed to second-hand smoke?
No
Packs per day _____ No.of years ____
Yes
Do you use illicit drugs No Yes Do you feel you have a dependency on any prescription drugs?
No
Yes
PAST MEDICAL HISTORY: (circle all that apply) Alcohol Dependency Anemia Anorexia/Bulimia Arthritis Asthma Back Trouble Bleeding Disorder Blood clots/phlebitis Bone Disorder Breast Lump Bronchitis Cancer___________ Cardiac arrhythmia /pacemaker Cataracts
Colitis Colon Polyp Diabetes-onset_____ Diverticulitis Emphysema Epilepsy/seizure Glaucoma Gout Hay Fever Heart Attack-date_____ Heart Failure Heart Murmur Hemorrhoid Hepatitis/liver disease
Hernia High blood pressure High Cholesterol HIV Positive Jaundice Kidney stone Migraine Headaches Mononucleosis Osteoporosis Pneumonia Prostate Problem Rheumatic Fever Sexually Transmitted Disease Sinus Disease
Skin Disorder Sleep Disorder Thyroid Problems Tuberculosis Ulcers Urinary Tract Infection: bladder or kidney
HOSPITALIZATIONS/SURGERIES: List illness or operation and approximate year: ____________________________________
Indicate any major childhood illnesses: _________________________________
____________________________________
_________________________________
INVESTIGATIONS: Please note if you have had any of the following Date / Location of Facility Bone density testing Colon scope Eye exam Flu Vaccine
________________ ________________ ________________ ________________
Mammogram _________________ Pneumovax _________________ Tetanus Vaccine________________
WOMEN ONLY: Date of last normal menstrual period _________________ Date of last PAP smear _________________ Menstrual problems _________________ Breast lumps _________________ Frequency and comfort level of breast exams _________________ Number of pregnancies _______
Number of miscarriages/abortions _______
MEN ONLY: Do you perform self-testicular exams? _________________ Date of last prostate exam _________________
FAMILY MEDICAL HISTORY Relation
Age
Health
Age of death Cause of death
Has your blood relative ever had any of the following? Disease Relationship to you Arthritis Asthma Cancer (location) Chemical dependency Diabetes Heart Disease/Stroke High Blood Pressure Tuberculosis Osteoporosis
Review of Systems Circle symptoms you currently have or have had in the past 1 year. GENERAL Chills Fever Night Sweats Hot Flashes Loss of Weight Loss of Appetite Anxiety Depression Frequent or severe headaches Loss of sleep Forgetfulness Excessive Thirst / Excessive Hunger
EYE,EAR, NOSE THROAT Blurred Vision Sudden changes in vision Double vision Blind Spots Difficulty Hearing Ringing in Ears Drainage from ears Bleeding gums Sores in mouth Nasal congestion Frequent nose bleeds Hay Fever Hoarseness Goiter Underactive thyroid Overactive thyroid
LYMPH GLANDS Swelling in the neck Swelling in the armpit Swelling in the groin
CARDIOVASCULAR Chest Pain Chest Discomfort Wake up short of breath Rapid heart beat Irregular heart beat Swelling in legs Varicose veins Low blood pressure Fainting Cramps in legs when walking
GASTROINTESTINAL Recent change in bowel movements Constipation Diarrhea Blood, pus or mucus in stools Abdominal pain Bloating after meals Heartburn/Indigestion Difficulty swallowing Nausea Vomiting Vomiting Blood Black Tarry Stools Frequent Antacid Use Rectal Bleeding Hemorrhoids
KIDNEY OR BLADDER Frequent Urination Lack of Bladder Control Painful Urination Blood in Urine Get up more than once at night to urinate
Review of Systems: Circle applicable symptoms SKIN Moles that have change in size or color Rash Bruise easily Hives Itching Sores that won’t heal
LUNGS Cough Coughing up blood Shortness of breath Get winded easily Wheezing Snoring Apnea MEN ONLY Lump in testicles Penis Discharge Sore on penis Prostate gland trouble Erection Difficulties
WOMEN ONLY Abnormal PAP smear Bleeding between periods Breast Lump Nipple Discharge Extreme Menstrual Pain Painful Intercourse Other Date of last menstrual period _______ Date of last PAP smear ___________ Birth Control Method ____________ Are you pregnant? Other MUSCLE, JOINT AND BONES Pain, weakness, numbness, swelling in Arms Hips Back Legs Feet Neck Hands Shoulder
Insurance Disclaimer/Financial Policy/Consent for treatment: □ □ □ □ □ □ □
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To assure that your insurance claims are processed correctly and in a timely manner, please make sure you advise us of any changes to your insurance information. Incorrect information will result in your claim being denied. I certify that the above information is correct and hereby authorize the release of medical information to my insurance company and/or to my referring physician. I assign to, North Georgia Internal Medicine (Bram Wieskopf, MD or Michael Skardasis, MD) any and all payments for services rendered to me (or my dependents). A copy of this authorization may be used in place of original. Insurance will be filed if the physician is covered under my plan. It is my responsibility to obtain a referral/order if required. I understand that I will be responsible for all non-covered services, co-payments and deductibles. All fees which are your responsibility are due at the time of your appointment. These include any co-payments, co-insurance, deductibles, or any other charges not covered by your insurance. Failure to pay at the time of your appointment will result in an additional $25.00 administrative service fee to be added to your bill. $25.00 Fee will be charged when a patient fails to provide us with at least 24 hour notice of cancellation, or is a “No Show” for the following service: “Follow-up” visits and sick/problem visits $50.00 Fee will be charged when a patient fails to provide us with at least 24 hour notice of cancellation, or is a “No Show” for the following services: • Annual Physical Examinations • All scheduled procedures, (Echocardiogram, Carotid, Bone Density Scan and Treadmill) • All New Patient Visits I agree to be evaluated and treated by one of the providers of NGIM, P.C. I the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to NGIM, P.C. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the release of all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions
Signature
Date
Research Opportunities Dr. Bram Wieskopf regularly conducts clinical trials, in order to offer our patients the widest possible choice of treatment options. Research trials are the standard process by which effective drugs are approved and made available through prescriptions to the population at large. Participants in clinical trials receive study-related physical exams, blood work, medication, and a modest payment for participation.
Signature
Date
North Georgia Internal Medicine, PC Informed Financial Consent Policy Effective January 1, 2012
Patient Cancellation and No Show Policy
In order to provide all our patients with the best care possible, we ask that you make every effort to keep your scheduled appointments and arrive at least 15 minutes early for your appointment. If you need to reschedule or cancel an appointment, we require a minimum of 24 hour cancellation notice. Adequate notice allows us to offer the appointment to another patient who needs to see the physician. Please remember that confirmation reminders from us are only a courtesy. Our failure to confirm your visit does not relieve you of your responsibility to cancel your appointment. To cancel or reschedule, please call our office at: ***678-494-4450***
$25.00 Fee will be charged when a patient fails to provide us with at least 24 hour notice of cancellation, or is a “No Show” for the following service: • “Follow-up” visits and sick/problem visits $50.00 Fee will be charged when a patient fails to provide us with at least 24 hour notice of cancellation, or is a “No Show” for the following services: • Annual Physical Examinations • All scheduled procedures, (Echocardiogram, Carotid, Bone Density Scan and Treadmill) • All New Patient Visits Failure to Pay at Time of Service
All fees which are your responsibility are due at the time of your appointment. These include any copayments, co-insurance, deductibles, or any other charges not covered by your insurance. Failure to pay at the time of your appointment will result in an additional $25.00 service fee to be added to your bill. Fees for Forms
To offset the overhead cost of the extensive administrative functions required by our physicians and staff, we are compelled to charge an Annual Administrative Service Fee of $20.00 per patient, per calendar year* This fee will be collected after your first visit with our practice *Copying of medical records request is priced individually. Please call our medical records department to determine your cost. Also this fee does not cover any charges for missed or “no show” appointments.
Patient Signature __________________________________________ Date _____________________
Patient Date of Birth _______________________________________
Consent to Use and Disclosure of Protected Health Information Use and Disclosure of Your Protected Health Information Your protected health information will be use by North Georgia Internal Medicine, P.C. or disclosed to others for the purpose of treatment, obtaining payment, or supporting the day-to day health care operations of the practice. Notice of Privacy Practices You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent. Requesting a Restriction on the Use or Disclosure of Your Information You may request a restriction on the disclosure of your protected health information. North Georgia Internal Medicine, P.C. may or may not agree to restrict the use or disclosure of your protected health information. It North Georgia Internal Medicine, P.C. agrees with your request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards. Revocation of Consent You may revoke the consent to the use and disclosure of your protected health information. You must revoke the consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. Reservation of Right to Change Privacy Practices North Georgia Internal Medicine, P.C., Reserves the right to modify the privacy practices outlined in this notice. Signature I have reviewed this consent form and give my permission to North Georgia Internal Medicine, P.C. to use and disclose my health information in accordance with it.
__________________________ Name of Patient (Print or Type)
____________________________ Signature of Patient
____________________________ Date
_______________________ Signature of Patient Representative
_____________________________ Relationship to Patient
