Patient Profile - Asheville Head, Neck and Ear Surgeons, PA

Currens Lane Melvin
Moore Rheney
Roberts
Seal Audio
Seal Roberts
Asheville Head, Neck and Ear Surgeons, P.A.
ID #: ________________
(For office use only)
Patient Profile
PATIENT INFORMATION
Legal Name: _________________________________________________________________________________________
First
Middle
Last
Preferred Name: ______________________ DOB: _____/______/______ Sex: M F SSN: _______-________-________
Mailing Address: ______________________________________________________________________________________
City
State
Zip
Physical Address: _____________________________________________________________________________________
City
Contact phone number: ____________________Cell/Home
State
Zip
Alt phone number: _____________________Cell/Home/Work
I authorize AHNE to leave messages on answering machine/voicemail of phone numbers listed above: YES
NO
Employer: __________________________________________________________ Retired Unemployed Student
Child
Marital Status: Married/Single/Divorced/Widow Language: __________ Race: ____________ Ethnicity: ___________
Email address: ______________________________________________________________ Portal sign-up? YES NO
Emergency Contact: _________________________________________________ Relationship to pt: __________________
Emergency Contact Phone number: _______________________ Alt phone number: ________________________________
PERSON RESPONSIBLE FOR PATIENT’S ACCOUNT (i.e. Guarantor, Parent, Guardian, etc.)
Legal Name: _________________________________________________________________________________________
First
Middle
Last
Relationship to patient: ________________ DOB: _____/______/______ Sex: M F SSN: _______-________-________
Mailing Address: __________________________________________________________________________________
City
State
Zip
Contact phone number: ____________________Cell/Home Alt phone number: _____________________Cell/Home/Work
Employer: ________________________________________________________________________ Retired Unemployed
PRIMARY INSURANCE
Subscriber’s Name: ____________________________________________________________________________________
First
Middle
Last
Relationship to patient: ________________________________ DOB: _____/_____/_____ SSN: ______-_______-_______
Insurance Company: ______________________________________ Employer: ___________________________________
SECONDARY INSURANCE **Please list other insurance coverage on the back of this form
Subscriber’s Name: ____________________________________________________________________________________
First
Middle
Last
Relationship to patient: ________________________________ DOB: _____/_____/_____ SSN: ______-_______-_______
Insurance Company: ______________________________________ Employer: ___________________________________
AUTHORIZATION **If there are additional authorized designees, please ask for additional form
I hereby authorize one or all of the designated parties below to request and receive the release of any protected health
information regarding my treatment, payment, or administrative operations related to treatment and payment. I understand
that the identity of designated parties must be verified before the release of any information.
Name: __________________________ Relationship to Patient: _______________________ Phone: __________________
Name: __________________________ Relationship to Patient: _______________________ Phone: __________________
Name: __________________________ Relationship to Patient: _______________________ Phone: __________________
Name: __________________________ Relationship to Patient: _______________________ Phone: __________________
Asheville Head Neck & Ear Surgeons, PA
Currens Lane Melvin Moore
Rheney Roberts Seal Audio
ID #: _____________
(For Office Use Only)
MEDICAL HISTORY
Date:
Home Phone:
Patient Name:
Age:
Referring Physician:
Family Physician:
(First and Last Name)
(First and Last Name)
Birthdate:
/
/
Brief reason for today’s visit:
Questions Regarding Patient (Check One)
Smoke
Previous Smoker
YES
YES
NO
Chew/Dip
Alcohol
Pregnant
Children
Married
YES
NO
YES
NO
YES
NO
YES
NO
Divorced
Packs per day
NO
- Number of years
Stopped for
years
YES NO
- If patient is child, does anyone in the household smoke?
Single
List Past Surgeries: (name and year of surgery)
Drinks per day
How Many?
Widowed
-If patient is child, do they live with parent or other?
Recreational drugs
YES
NO
Past Medical History: Please complete the questionnaire to the best of your memory. If there is a question about an
item, please ask for assistance. Check yes or no for each item. Thank you.
Cardiovascular
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Heart attack
Heart failure
High blood pressure
Circulation problems
High Cholesterol
Pulmonary
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Endocrine
YES
YES
Diabetes
Thyroid disease
Skin
YES
YES
NO
NO
Do you have or have you been treated for:
YES
NO
Hepatitis A, B, C
YES
NO
TB (tuberculosis)
YES
NO
HIV/AIDS
YES
NO
CMV virus
YES
NO
MRSA
NO
NO
Intestinal
YES
NO
YES
NO
YES
NO
Asthma
Emphysema
Sleep apnea
C pap machine
Pulmonary
embolus
Eczema
History of skin
cancer
Stomach / ulcers
Jaundice
GERD
Child Immunology
YES
NO Current Immunizations
Other Medical Problems:
Urinary
YES
YES
NO
NO
Kidney stones
Prostate problems
Orthopedic
YES
NO
Arthritis
Neurologic
YES
NO
YES
NO
YES
NO
Stroke / CVA
Seizures
Glaucoma
Hematology / Lymphatic
YES
NO
History of blood
clots or DVT
YES
NO
Lymphoma
YES
NO
Bleeding disorder
Cancer
YES
YES
NO
NO
YES
NO
Thyroid cancer
Head & neck
cancer
Other:
Family History: Please specify which member of your family (mother, father, sister, brother, grandparents) have had the following medical problems.
YES
NO
Cancer (what kind)
YES
NO
Reactions to Anesthesia
YES
NO
High blood pressure
YES
NO
Diabetes
YES
NO
Heart attack
YES
NO
Hearing loss
YES
NO
Bleeding problems
YES
NO
Other diseases
Form completed by:
Signature:
    OVER    
List Medications: (include those you buy without a
prescription, include vitamins & natural products):
Medications Patient is Allergic to: (list reactions)
PHARMACY INFORMATION Please provide at least the name and approximate location for prescription purposes.
Name:
Phone Number:
Address:
City:
State:
Current Symptoms: Please complete the questionnaire to the best of your memory. If there is a question about an item, please
ask for assistance. Circle yes or no for each item. Thank you.
Ear
YES
YES
YES
NO
NO
NO
Hearing loss
Ringing in the ears
Ear pain
Nose
YES
NO
Nasal obstruction
Throat
YES
YES
YES
NO
NO
NO
Cardiovascular
YES
NO
YES
NO
YES
NO
Eyes
YES
YES
NO
NO
Difficulty swallowing
Hoarseness
Sore throat
Irregular heartbeat
Angina or chest pain
Shortness of breath
with exertion
Double vision
Change in vision
Allergy/Immunology
YES
NO
Seasonal allergies
YES
NO
Allergy skin test
positive
YES
NO
Itchy eyes
YES
NO
Itchy nose
Endocrine
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Pulmonary
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Skin
YES
YES
NO
NO
Intestinal
YES
NO
YES
NO
YES
NO
YES
NO
Constitutional
YES
NO
YES
NO
YES
NO
YES
NO
Excessive thirst
Excessive urination
Hormone problems
Heat intolerance
Cold intolerance
Snoring
Chronic cough
Coughing up blood
Shortness of breath
Wheezing
Rashes
Scar easily
Indigestion
Vomit blood
Change in bowel
habits
Heartburn
Night sweats
Weight loss
Fatigue
Fever
Urinary
YES
NO
YES
YES
NO
NO
Orthopedic
YES
NO
YES
NO
YES
NO
Neurologic
YES
NO
YES
NO
YES
YES
NO
NO
Difficulty
urinating
Blood in urine
Recurrent UTI
Spine problems
Bone problems
Numbness in
hands or feet
Headaches
Weakness or
numbness
Depression
Dizziness
Hematology / Lymphatic
YES
NO
Bleed/bruise easily
YES
NO
Anemia
Currens Lane Melvin
Moore Rheney
Roberts Seal Audio
Asheville Head Neck & Ear Surgeons, PA
PATIENT POLICIES
ID #:____________
(For Office Use Only)
Thank you for choosing our practice for your health care. In order to assist you in
understanding and managing your responsibilities as a patient in our office, we have developed
a financial policy, as well as, some general office policies which will help prevent unnecessary
increases in your medical bills. Please read and sign this policy prior to your visit with our
physician.
1. Our office requires that you fully complete a patient information form, which includes all
current insurance information for the patient.
2. Payment in full is expected at the time of service. We accept personal checks, cash, Visa,
Mastercard, and Discover. AHNE will expect full payment of copays, coinsurance and
deductibles at the time of service if your visit is covered by an insurance plan with which
we participate. Non-emergent visits will be rescheduled if you are unable to pay the
copayment or coinsurance at the time of the visit.
3. Insurance claims:
Office visits: AHNE will file claims with all insurance companies though we will collect
payment in full at the time of service if we do not participate with your insurance.
Surgeries: AHNE will file claims with all insurance companies for surgical claims. Any
noncovered surgical expenses must be paid in full prior to the surgery. Copayments and
deductibles will be collected prior to surgery.
4. If you have unique financial problems, please discuss them with us.
5. Please be advised that AHNE works with a professional collection agency and any unpaid
accounts will be given to this agency for collection efforts. This would affect your credit
rating and show on your credit report.
6. Please understand that your insurance coverage is a contract between you, your employer and
your insurance company. You are responsible for any balance not paid by your insurance
company in 30 days for the date of services.
7. The adult, parent or guardian, accompanying a minor to our office will be regarded as
responsible for all balances and transactions for the patient. We will not serve as an
intermediary. Unaccompanied minors will not be seen in our office except on an
emergency basis.
8. Medicaid patients must present a current Medicaid card at the time of each visit. Adults will
also be expected to have their $3.00 copayment at the time of their visit. Your appointment
will be rescheduled if you do not pay your copay before being seen.
9. A physician is always on call for emergency care for our office. Please limit requests for
appointments and prescription refills to our regular office hours between 9AM and 5PM.
After hours calls will be answered by our answering service who will have a physician return
your call.
10. Failure to uphold the terms of these policies may result in dismissal from AHNE.
11. Comments:_________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
I have read and understand this financial policy. I accept the terms of the policy.
Signature:____________________________________________ Date: __________________