New Patient Medical Packet

Choose an office: *

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Patient Information:

Patient First Name

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Middle Initial

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Patient Last Name

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Date of Birth:

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Gender

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Marital Status:

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Address:

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City:

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State:

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Zip Code:

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Cell Number:

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Home Number:

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Social Security Number:

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Race:

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Ethnicity:

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Language:

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Patient Employer

Patient Employer:

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Address:

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Phone:

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Person Responsible for Bill:

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Date of Birth:

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Address(If different from patient):

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Patient Pharmacy

Pharmacy Name:

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Pharmacy Address:

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Pharmacy City:

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Pharmacy State:

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Pharmacy Zip Code:

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Permission to view Prescription History from External Sources:

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Primary Care Physician

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Referred By:

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Emergency Contact:

Emergency Contact Name:

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Relationship:

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Contact Number:

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Address:

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Primary Insurance

Name of Company:

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Subscriber Name:

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Subscriber Date of Birth:

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Subscriber Relationship:

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Policy Number:

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Group Number:

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Secondary Insurance

Name of Company:

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Subscriber Name:

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Subscriber Date of Birth:

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Subscriber Relationship:

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Policy Number:

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Group Number:

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I acknowledge receipt of notice of privacy practices (HIPAA) is on the above website and copy of it for the review is available upon request.

I authorize Southland Rheumatology Center to release information regarding services rendered and allow a photocopy of my signature to be used to file insurance.

I authorize and direct my insurer to issue payment for services directly to Southland Rheumatology Center. If my insurance is MEDICARE, I request the payment of authorized MEDICARE benefits, for any services furnished to me, to be made on my behalf, to Southland Rheumatology Center.

In the event of non-payment, I understand that I am responsible for collection, attorney, and court costs.

I authorize any holder of medical information about me to release to the HEALTHCARE FINANCING ADMINISTRATION and its agents any information needed to determine those benefits payable for related services.

Dr. Nayak is NOT a MEDICAID Provider.

FAILURE TO PROVIDE SECONDARY INSURANCE INFORMATION PRIOR TO VISITS WILL RESULT IN PATIENT BEING RESPONSIBLE FOR BALANCE ON ACCOUNT.

Please sign your name in the area below

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date:

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NEW PATIENT MEDICAL FORM

Reason for the Visit Today

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Pain Level:

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Please list any RECENT, X-Rays, MRI’s, CT scans done in last 6 MONTHS and WHERE they were done?

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List All your Medications with Dosages including Over the Counter Non-Prescriptive Supplements.

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Do you have any ALLERGIES to any Medications?

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If yes, please list

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List any MEDICAL CONDITIONS you have had, and Date of Diagnosis

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List any SURGERIES you have had, and Date of Diagnosis:

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System Review

Please Check Any Symptoms You Are Currently Experiencing

Fever

Chills

Night Sweats

Recent Weight Loss

Recent Weight Gain

Fatigue

Difficulty Sleeping

Neck Pain

Back Pain

Dry Eyes

Double / Blurred Vision

Ringing in Ears

Frequent Nosebleeds

Dry Mouth

Frequent Mouth Sores Check

Chest Pain

Irregular Heartbeat

High Blood Pressure

Shortness of Breath

Cough

Wheezing

Swollen Legs / Feet

Changes in Mood

Headaches

Dizziness / Imbalance

Fainting

Tingling / Numbness

Muscle Weakness

Muscle Spasm

Muscle Pain

Difficulty Swallowing

Heartburn

Stomach Pain

Diarrhea

Constipation

Nausea

Memory Problems

Loss of Appetite

Thyroid Abnormalities

Skin Rash

Sun Sensitivity Rash

Excessive Hair Loss

Color Change in Hands / Feet

Easy Bruising

Pain / Burning / Frequent Urination

Do You Smoke?

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If yes, how much?

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Do you drink alcohol?

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If yes, how much?

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Do you use CBD

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If yes, how much?

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Have you had Osteoporosis Screening w/Bone Density Test?

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If yes, when?

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Have you had a Pneumonia Vaccination

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If yes, when?

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Have you had COVID-19 Vaccination

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If yes, when?

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Have you had Shingles Vaccination

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If yes, when?

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Family Health History (Please list their Significant Health Problems)

Father:

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Mother:

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Siblings:

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Children:

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Is there a Family Medical History of the following conditions:

Autoimmune Connective Tissue Disease like Lupus or Rheumatoid Arthritis?

Please select an option.

If yes, who?

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Osteoarthritis

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If yes, who?

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Gout / Kidney Stones

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If yes, who?

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Osteoporosis:

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If yes, who?

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Cancer

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If yes, who?

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Heart Disease

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If yes, who?

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Diabetes

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If yes, who?

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Billing Policy

Patient benefits will be verified with insurance prior to your office visit and co-pay will be collected at the time of service by cash or credit card (NO CHECKS).

ALL CO-PAYS ARE DUE AT THE TIME OF SERVICE.

Deductibles will be collected in full at the time of follow up appointment, after insurance has processed claims.

Patients with outstanding balances will be requested to pay the balance in full, prior to their appointment, by cash or credit card (NO CHECKS).

If amount remains unpaid after 90 days, the account will be referred to collection agency and an additional 10% fee will be applied to cover collection fee.

NO SHOW/CANCELATION POLICY:

Any cancellation for an appointment without a 24-hour notice, depending on the circumstances of course, there will be charge a $25, that will have to be collected at the time of your next visit by cash or credit card.

If you do not show up for an appointment, there will be a $25 charge, that will have to be paid at the time of your next visit.

If you do not show up/cancel an appointments 3 times consecutively, we will not be able to schedule any further appointments with our practice.

NOTICE TO ALL HMO PATIENTS

It is the patient’s responsibility to obtain valid updated referrals for each office visit. If for some reason you do not have a referral to cover services here in our office, your appointment will be cancelled. Any office visits that do not have a referral to cover the services, the patient will be responsible for any balance, which your insurance will not cover without having a referral.

NOTE: If you need to cancel your appointment prior to the scheduled date, and we are not in the office, you are always welcome to leave a message with our answering service at 708-283-2600.

Signature:

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date:

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Patient Consent:

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.

Obtain payment from third-party payers.

Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed the Notice of Privacy Practices containing a more complete description about the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that Southland Rheumatology Center has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing to restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

HIPAA DISCLOSURE AUTHORIZATION

I authorize Southland Rheumatology Center to speak with and disclose information about my medical conditions to the following persons:

Name:

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Relationship:

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Name:

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Relationship:

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I, further authorize Southland Rheumatology Center to contact me and leave messages on:

Home Phone:

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Cell Phone:

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Email:

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This authorization will remain in place until rescinded by me.

Patient First Name

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Patient Last Name

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Signature

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Date:

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