kidney care physicians, llc 875 oak st se suite … care physicians, llc. 875 oak st se suite #5070...
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Kidney Care Physicians, LLC875 Oak St SE Suite #5070 Salem, OR 97301Phone (503) 561-8565 Fax (503) 561-8560
Denis Privalov MDEva Lee MD
Brett Mikeska MD
Lance Dicker MD
Misha Mohindra MD
Andreea Andone MD
Aneet Deo MD
Dear
You have an appointment scheduled withThis appointment will take approximately one hour. We would like to take this opportunity to familiarize you with some of our clinic procedures.
YOUR SCHEDULED APPOINTMENT TIME IS VERY IMPORTANT. PLEASE ARRIVE 20 MINUTES BEFORE YOUR SCHEDULED APPOINTMENT TIME. PLEASE REMEMBER TO ALLOW TIME FOR PARKING AT THE SALEM HOSPITAL.
BRING A LIST OF MEDICATIONS YOU ARE TAKING INCLUDING THE STRENGTH AND DOSAGE. A URINE SPECIMEN WILL BE NEEDED AT YOUR APPOINTMENT TIME, SO PLEASE PLAN ACCORDINGLY.
Co-payments are expected at the time of service and will be collected prior to your appointment with our physician. If you have a managed care insurance that requires a referral or prior authorization from your primary care physician, please contact your primary care physicians to get the referral or prior authorization.
Please complete the enclosed registration forms and return all 5 pages front and back in the self addressed, postage paid envelope as soon as possible. Kidney Care Physicians will bill your primary, secondary, and tertiary insurance plans as a courtesy to you. Please remember to bring a copy of your current insurance card with you. Be aware that the HIPAA act requires us to verify your identity. Please be ready to produce a valid photo ID this would include a state drivers license, state photo ID card, or military photo ID. We will be taking a photo of you to attach to your electronic chart.
IF YOU ARE UNABLE TO KEEP THIS APPOINTMENT PLEASE CONTACT OUR OFFICE 24 HOURS PRIOR TO YOUR APPOINTMENT TIME AS THERE ARE OTHER PATIENTS THAT COULD BE SCHEDULED AT THIS TIME WITH OUR DOCTORS.
If you have any questions regarding our clinic or these procedures, please call our office.
Enclosures: 1. Appointment Card with Date and Time. 2. Patient Demographic Sheet 3. Financial Policy Form 4. Missed Appointment Policy 5. Acknowledgement and Consent Form 6. HIE Consent Form 7. Patient Medication and History Forms 8. Map With Directions To Kidney Care Physicians, LLC 9. Postage Paid Self Addressed Envelope
Patient Name:
Patient Demographic Information Sheet
Last Name: First Name: Middle Int:
Nickname:
Address
City State Zip Code Zip CodeStateCity
Address
Please fill out form in black or blue ink. Please fill the form out completely and to the best of your knowledge. Return this form to the front desk at Kidney Care Physicians, LLC.
Date of Birth: SSN Number:
Physical Address if Different:Mailing Address/PO Box:
Primary Language: Ethnicity:
Please Check One
Marital StatusPlease Check One
Student Status
Are you a veteran?
Primary Care Physician: Primary Pharmacy:
Other Physicians Participating in Your Care to Send Records to:
Cell Phone: Work Phone:
E-mail Address:
Home Phone:
Please Check Your Preferred Method of Communication:
Emergency Contact Person Contact Phone:Relation:
Sex:
Race:
Please Check One
Confidential Information
Are you currently using tobacco products?
Primary Ins: Secondary Ins:
Please Enter Your Insurance Information Below:
Policy#: Policy#:Group#: Group#:
Decline to Report
Non Hispanic or Latino
Hispanic or Latino
Divorced Legally Separated
Life Partner Married Single Widowed
Please Check One
Full Time Part Time Not A Student
Yes
No
Yes
No
Signature:
Description of Representative's Authority and Patient Name:
-OR-
Print Name:
Date Signed:
Date Signed:
Print Name:
Signature:
Patient Representative
Date of Birth:
I have read and understand the Financial Policy above.
Kidney Care Physicians asks that you read and sign this Financial Policy prior to any treatment. Please let us know if you have any questions.
• We will verify your insurance coverage at every visit. It is the patient's responsibility to supply all current insurance cards at each visit. • All Co-pays are due at the time of the visit. • We will ask you for picture identification for identity verification. • We will take your picture as part of our Red Flag Policy to ensure against identity theft. • If you do not have insurance or cannot provide proof of insurance at the time of your initial visit, a pre-payment of $100.00 will be required before services are provided. • We accept cash, checks, money orders, and most major credit cards. • Payment plans can be arranged with the billing office.
As a courtesy to our patients, we will submit claims to your insurance carrier for you. We will also submit secondary and tertiary claims. Insurance plans vary considerably and we cannot predict or guarantee what part of our services will or will not be covered by your plan. The patient is responsible for knowing the details/rules of his/her health plan(s). I hereby authorize Kidney Care Physicians LLC to release any medical information required in the course of treatment to permit payment directly to them from the insurance carrier. I recognize and accept responsibility for services rendered regardless of insurance coverage. This includes, but is not limited to, Co-Payments, Co-Insurance, Deductible, and Non-Covered Services.
FINANCIAL POLICY
Signature:
Description of Representative's Authority and Patient Name:
-OR-
Print Name:
Date Signed:
Date Signed:
Print Name:
Signature:
Patient Representative
Date of Birth:
MISSED OR LATE APPOINTMENT POLICY
Kidney Care Physicians asks that you read and sign this Missed or Late Appointment Policy prior to treatment in our office. Our policy is to call patients one day prior to the appointment to remind them of the date and time. These calls are a courtesy to our patients and it allows us the opportunity to schedule another patient in that appointment time if you choose to cancel. Missed appointments or arriving late for an appointment prevents other individuals from seeing there provider in a timely manner. Please note that a pattern of missed appointments, last minute cancellations, or being late for the scheduled appointment will result in possible discharge from Kidney Care Physicians. As a courtesy to other patients Kidney Care Physicians asks that you arrive 20 minutes prior to your scheduled appointment time. If you are 15 minutes passed your scheduled appointment your provider may not be able to see you and you will be asked to reschedule the appointment. If you are unable to keep your scheduled appointment, call us 24 hours prior to your scheduled appointment. If we do not receive a call and you miss your appointment there may be a $50.00 fee assessed to your account for that missed appointment. You will be responsible for this payment as your insurance will not pay this fee and it will be due prior to scheduling another appointment. Please call and ask for the Billing Office to settle this payment and schedule a new appointment at your convenience. Kidney Care Physicians gives you the right to appeal any or all charges or fees assessed to your account. If you have any questions or would like to appeal a fee assessed for a missed appointment please call (503) 561-8565 and ask for the office manager.
I have read and understand the Missed or Late Appointment Policy above.
Signature:
Description of Representative's Authority and Patient Name:
-OR-
Print Name:
Date Signed:
Date Signed:
Print Name:
Signature:
Patient Representative
Date of Birth:
ACKNOWLEDGEMENT AND CONSENT
I understand that Kidney Care Physicians LLC (referred to below as KCP) will use and disclose health information about me. I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnosis, treatment, procedures, prescriptions, and similar types of health-related information. I understand and agree that KCP may use and disclose my health information in order to:
• Make decision(s) about and plan for my care and treatment; • Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment; • Determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and • Perform various office; administrative and business functions that support my physician's efforts to provide me with, arrange and be reimbursed for quality cost-effective health care.
I also understand that I have the right to receive and review a written description of how KCP will handle health information about me. This written description is known as a Notice or Privacy Practices and describes the uses and disclosures of health information and my rights regarding my health information. I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy of the most current version of This Practice's Notice of Privacy Practices in effect can be found in the waiting/reception area or on the company website. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests. By signing below, I agree to and understand the information above:
Signature:
Description of Representative's Authority and Patient Name:
-OR-
Print Name:
Date Signed:
Date Signed:
Print Name:
Signature:
Patient Representative
Date of Birth:
I understand that Kidney Care Physicians LLC (referred to below as KCP) may disclose my Protected Health Information (referred to below as PHI) electronically to or from other covered entities for coordination of patient care. The Health Portability and Accountability Act (HIPAA) states the patient has the right to choose to opt-in or opt-out of the electronic transfer of their PHI. Benefits of (HIE) or Electronic Information Transfer: * Information exchange that is more secure and efficient for patient coordination of care between your primary care, specialists, and medical facilities. * Higher levels of minimum necessary access and file encryption. * An automated and faster response time for information after request is placed. I understand that there is no Oregon Law or HIPAA Law that requires KCP to obtain consent to disclose patient information electronically for treatment, payment, and healthcare operations. I understand that KCP will need a separate form to disclose PHI that involves HIV, Mental Health, Drug and Alcohol Abuse, or Sexually Transmitted Diseases/Infections. I understand that KCP at times many be required by Federal or State law to disclose patient information as stated in the Notice of Privacy Practices. ____ OPT-IN: By opting in your are giving consents for KCP to release your PHI electronically for the above purposes of coordination of care with other covered entities. ____ OPT-OUT: By opting out you are not giving KCP consent to release your PHI electronically for the above purposes of coordination of care with other covered entities even in an emergency but will continue to be released through faxing, phone, or postal services. I understand that by initialing one of the above boxes that KCP will send my PHI in my desired format and that I have the right to change my decision at any time after this form is signed. If I change my decision after signing this form I need to inform KCP in writing or complete the appropriate form with signature and date. I understand that if I change my decision KCP is not responsible for the already sent information prior to the date of the new signed form. If you have any questions regarding the safeguards, manner of transmission, collections of PHI for coordination of care, or other HIE concerns, please contact the HIPAA Official for Kidney Care Physicians at (503) 561-8565. I have read, reviewed, and initialed the appropriate line above and with my signature acknowledge the format in which I would like my PHI sent and received by KCP.
AUTHORIZATION FOR (HIE) OR ELECTRONIC TRANSFER OF PROTECTED HEALTH INFORMATION
Medication and Allergy Information SheetConfidential Information
Please list all of your Allergies to Medications, Food, or the Environment and the reaction(s).
Please list all of your current Medications, Dose, and Directions.
Please list all of your current over the counter Medications, Dose, and Directions.
NSAID (Nonsteroidal Anti-Inflammatory Drug) Usage
Advil Use Never Use
Occasional Use
Daily Use
Amount Per Day
Aleve Use Never Use
Occasional Use
Daily Use
Amount Per Day
Ibuprofen Use Never Use
Occasional Use
Daily Use
Amount Per Day
Motrin Use Never Use
Occasional Use
Daily Use
Amount Per Day
Naproxen Use Never Use
Occasional Use
Daily Use
Amount Per Day
Other NSAID Use Never Use
Occasional Use
Daily Use
Amount Per Day
Please fill out form in black or blue ink. Please fill the form out completely and to the best of your knowledge. Return this form to the front desk at Kidney Care Physicians, LLC.
Patient Health History SheetConfidential Information
Please check if you have been diagnosed with any of the problems listed below.
Deafness
Other Hearing Problems
Blindness
Cataract
Glaucoma
Other Visual Problems
Lung Disease
Asthma
Emphysema
Chronic Bronchitis
COPD
Tuberculosis
Chronic Cough
Pneumonia
Wheezing
Shortness of Breath
Eyes, Ears, Nose, and Throat LungsHeart Disease
Heart Attack
Congestive Heart Failure
Enlarged Heart
Angina
High Blood Pressure
Irregular Heart Beats
Pacemaker/Defibrillator
Cardiac Catheterization
Angioplasty
Heart
Valvular Disease
Other Heart Disease
Thyroid Disease
Adrenal Disease
Diabetes (Non-Insulin)
Diabetes (Insulin)
Endocrine
Kidney Failure
Ever Been on Dialysis
Kidney Stones
Prostate Problems
Prostate Cancer
Venereal Disease
Kidney and Genital
Other Kidney Disease
Stomach Ulcers
Jaundice
Liver Disease
Hepatitis
Irritable Bowel Syndrome
Gastrointestinal and Stomach
Crohn's Disease
Other Stomach Disorder
Other Bowel Disorder
Stroke
Epilepsy or Seizures
Mental Retardation
Brain Injury
Nerve Injury
Memory Problems
Nervous System
Disc Disease
Blackout/Fainting Spells
Migraine Headache
Skin Disorder
Joint Disease
Arthritis
Osteoarthritis
Muscles and Bones
HIV or AIDS
Other STDS
Other Problems
Please give more detail if you have checked one of the "Other" or "Cancer" boxes. (Example: location and severity)
Ulcerative Colitis
Cancer
Lymphoma
Leukemia
Anemia
Platelet Disorder
Bone Marrow Disorder
Spleen Disorder
Hematology/Oncology
Please fill out form in black or blue ink. Please fill the form out completely and to the best of your knowledge. Return this form to the front desk at Kidney Care Physicians, LLC.
Please list any previous hospitalizations/procedures and dates.
Patient Health History SheetConfidential Information
Family History Father At What Age? Mother At What
Age? Siblings At What Age? Children At What
Age?
Heart Disease
Hypertension
Stroke
Migraine Headache
High Cholesterol
Seizure
Asthma/COPD
Diabetes
Cancer
Kidney Disease
Congestive Heart Failure
Other
Please fill out form in black or blue ink. Please fill the form out completely and to the best of your knowledge. Return this form to the front desk at Kidney Care Physicians, LLC.
If you have checked any "other" box(es) please describe here or offer other comments:
Social History
Cigarette Tobacco Use
Never Use
Occasional Use
Regular Use
Packs Per Day
Chewing Tobacco Use
Never Use
Occasional Use
Regular Use
Amount Per Day
Alcohol Use Never Use
Occasional Use
Regular Use
Drinks Per Day
Illicit Drug Use
Never Use
Occasional Use
Regular Use
Route and
Type
Living Status Alone With Spouse With Family Member
With Caregiver
Assisted Living
Care Facilty
Any other comments you might have that apply to your social habits:
Occupation: Employer:Education Level:
Patient Present Health SheetConfidential Information
Are you experiencing any of the following conditions now?
Fever Chills Weight Gain Weight Loss Weakness Night SweatsGeneral
Blurry Cataracts Eye Pain Floaters Black SpotsVision
Sore Throat Ear Pain Nose Bleeds Sinus Problems Hearing LossEars, Nose, Throat
Chest Pain Irregular Heart Beat SwellingCardiac
Swelling Location(s): _______________________________________
Shortness of Breath Cough Pain with Breathing Wheezing Bloody PhlegmRespiratory
Stomach Pain Heart Burn Nausea Vomiting Diarrhea ConstipationGastroenterologic
Appetite Loss Appetite Gain
Urine Urgency Urine Frequency Burning Urination Difficulty with Urination
Erectile Dysfunction
Urinary
Rash Bruising Lesions ItchingSkin
Headache Dizziness Seizures NumbnessNeurologic
Depression Anxiety Insomnia Memory Loss ADHDPsychological
Heat Intolerance Cold Intolerance Hair Loss Energy Up Energy DownEndocrine
History of Falls Back Pain Joint Pain Anemia Weakness Night SweatsMisc
Weakness
Bloody Urine
Bloody Stools Dark or Tarry Stool
Tremors
Please fill out form in black or blue ink. Please fill the form out completely and to the best of your knowledge. Return this form to the front desk at Kidney Care Physicians, LLC.