munroe regional medical center -...

Dear______________________;

On behalf of Munroe Regional Medical Center we thank you for choosing Ocala Surgical Associates at Munroe for your healthcare needs. We look forward to meeting you at your scheduled appointment.

To make your fi rst visit to our offi ce easier, we ask that you complete the enclosed information forms entirely and mail it back at least 5 days prior to your appointment date.

Your appointment is scheduled _____________ at _________ 1541 SW 1st Avenue #105, Ocala, FL 34471offi ce.

Please arrive to your appointment 15 minutes prior to the scheduled time and have your insurance cards and picture I.D. available for insurance verifi cation purposes.

***If you have an Advanced Directive, (Living Will) please bring it in for your records.

We welcome you to our practice and look forward to meeting you and helping with your healthcare needs.

Sincerely,

Munroe Professional Services

Ocala Surgical AssociatesMunroe Regional Medical Center

OSA-170 (08/12)

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PATIENT INFORMATION SHEET

Patient Name: First Middle Initial Last

Person fi lling out information: __________________________ Relationship to Patient:

DOB: ____________________ Age: ______________Height: _____________Weight: _________________Sex:_______________

Right Handed: _______Left Handed: _______

Ethnicity: Hispanic or Latino_______ Not Hispanic or Latino_______ Decline________

Family Physician: Phone #

Referring Physician: Phone #

Other Doctors following patient:

1. Doctor: _______________________ Phone #________________ For/Problem_____________________________



Reading Preference � English � Spanish � Other � Unable to read/writeLearning Barrier � None � Blind � Deaf � MemoryLearning Preference � Class/Group � Demonstration � Explain/Discuss � Handout � Video

Employment (include job title, description and length of time at work place):


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LAST NAME FIRST MIDDLE

SOCIAL SECURITY NUMBER DATE OF BIRTH AGE SEX

LOCAL MAILING ADDRESS APT# CITY STATE ZIP

HOME PHONE CELL PHONE MARITAL STATUS REFERRING PHYSICIAN

PERMANENT PHYSICAL ADDRESS or same as above EMAIL ADDRESS

PATIENT’S EMPLOYER EMPLOYER ADDRESS BUSINESS PHONE

SPOUSE’S NAME SOCIAL SECURITY NUMBER DATE OF BIRTH

SPOUSE’S EMPLOYER EMPLOYER ADDRESS SPOUSE’S BUSINESS PHONE

NEAREST FRIEND/RELATIVE (not residing with you) RELATIONSHIP

ADDRESS PHONE NUMBER

MEDICAL INSURANCE INFORMATION

PRIMARY INS. CO. NAME OF INSURED RELATIONSHIP TO PT. DOB SOCIAL SECURITY#

POLICY NUMBER ADDRESS PHONE NUMBER

AUTHORIZATION/PRECERT REQUIRED: YES NO 2ND OPINION REQUIRED YES NO

SECONDARY INS. CO. NAME OF INSURED RELATIONSHIP TO PT. DOB SOCIAL SECURITY#

POLICY NUMBER ADDRESS PHONE NUMBER


PATIENT INFORMATION / INSURANCE1A

1541 SW 1st Avenue Suite 105 / Ocala, FL 34471Phone: 352-622-8152 Fax: 352-622-4408

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Please take a few moments to fi ll out the following medical history form to the best of your ability

Past Medical History

Allergies

Your Name: Today’s Date: Surgery Date:

Present Age: Home Phone#

Briefl y describe your current medical problem and symptoms:

� Rheumatic Fever � Cancer � Heart Attack � Stroke � Ulcers� Mitral Valve Prolapse � Heart Murmur � Kidney Disease � Phlebitis � Asthma� High Blood Pressure � Hiatal Hernia � Epilepsy � Diabetes � Herpes� Nervous Disorder � Yellow Jaundice � Thyroid Disease � Emphysema � Glaucoma� Heart Trouble � Bronchitis � Hepatitis � Pneumonia� Other:

Please List All Current Medications Including Any Vitamins/Herbals OR Aspirin

Name Strength How Many - How Often

To What Medications:

Types of Reactions:

Other:

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Past Surgeries (Use the back of this sheet if you need more space)

Family History

Social History

Type Date Complications

Have you ever had a problem with either a local or a general anesthesia? Yes No

If YES, Please Explain:

Has anyone in your immediate family ever had:

Check Box that Applies: Identify Blood Relative

Diabetes � Yes � No

Heart Disease � Yes � No

High Blood Pressure � Yes � No

Stroke � Yes � No

Cancer � Yes � No

Lung Disease � Yes � No

Kidney Disease � Yes � No

Other Signifi cant Family Disease:

� Single � Married � Widowed � Separated � DivorcedNumber of Children: Number living at home: Patient Lives: Alone With Spouse With Relative Patient Lives At: Home Assisted Living Facility Nursing Home “I feel safe at home” Yes No Occupation: Do you smoke? Yes No How much per day? Do you chew tobacco? Yes No How much per day? If NO to the above questions, then did you ever smoke? Chew? When did you start? When did you quit? Any alcohol/beer consumption? Yes No How much per day/week? Any type of “street drugs”? Yes No What type and how often?

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Please check box for any of the following which you have RECENTLY experienced.

General: � Fever � Chills � Weight Loss � Weakness � Loss of Appetite � Night Seats

Head: � Seizures � Migraines � Poor Hearing � Earaches � Visual changes � Voice Changes � Sinus Problems � Allergies � Nose Bleeds � Wear Glasses � Wear Contacts � Dentures � Hearing Aides � Sore Throats � Cold/Flu Symptoms

Heart: � Palpitations � Chest pain � Chest Tightness � Angina � Racing Heart � Irregular Beats � Heart Attack � High Cholesterol � Shortness of Breath � Swollen Ankles � High Triglycerides

Lungs: � Cough � Phlegm � Cough up Blood � TB � Pneumonia � Bronchitis � Abnormal Chest X-ray

Breasts: � Lumps � Pain � Tenderness � Swelling � Redness � Nipple Inversion � Nipple Discharge � Nipple Bleeding Date of last beast exam: Date of last Mammogram:

GI: � Vomiting � Stomach Pains � Nausea � Jaundice � Loose Bowels � Vomiting Blood � Constipation � Indigestion � Heartburn � Hemorrhoids � Gas

GU: � Frequent Urination � Burning Urination � Blood Urine � Kidney Stones � Kidney infection � Bladder infection

Blood: � Anemia � Bruise Easily � Abdominal Bleeding � Abnormal Clotting � Exposure to AIDS Have you ever had a blood transfusion? Yes No

Skin: � Allergies � Rashes � Itching � Change in Nails � Hives � Skin Cancer


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Review of Symptoms

Women Only

First day of last menstrual period:

Number of pregnancies: Live Births:

Miscarriages: Abortions:

Date of last PAP Test:

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1B

INSURANCE CERTIFICATION FOR PAYMENT

I/we authorize MRHS dba Munroe Professional Services, as agent for the group or groups of physicians that render medical services to me, to bill the above-named insurance company or companies for such medical services, and I/we hereby assign the benefi ts payable from the above-named insurance company or companies to MRHS dba Munroe Professional Services, as agent for the physician group or groups. In connection with the foregoing, I/we hereby authorize MRHS dba Munroe Professional Services and the physician group or groups that render medical services to me to release to the above-named insurance company or companies any information needed for collection of benefi ts on my/our behalf. Further, I/we agree to forward any insurance payments paid to patient and/or subscriber for services rendered by MRHS dba Munroe Professional Services or affi liated physicians.

MEDICARE CERTIFICATION FOR PAYMENT

I/we certify the information provided by me/us in applying for payment under the Title XVII of the Social Security Act is correct. I/we authorize MRHS dba Munroe Professional Services and its affi liated physicians to release to the Social Security Administration or its intermediaries or carriers any information needed for Medicare claims fi led by them on my behalf. I request the payment of authorized benefi ts be made on my behalf. Additionally, I/we assign benefi ts payable for physician services to the physician, physician group or organization furnishing the services. Further, I/we request the above authorization to apply to the secondary or Medigap policy as refl ected on page one.

CONTINUING RESPONSIBILITY

Notwithstanding the foregoing information, the undersigned fully understand and hereby acknowledge and agree that, if the services to be rendered are covered by any insurance or employee benefi t program other than a health maintenance organization, or if the undersigned has/have no such coverage, then the undersigned is/are directly and completely responsible to MRHS dba Munroe Professional Services and its affi liated physician group(s) for payment of all medical bills submitted by them for services rendered to the above-named patient, whether or not any benefi ts are recovered from such insurance or employee benefi ts plan. I/we agree to forward any insurance payments to patient/subscriber for services rendered by MRHS dba Munroe Professional Services or affi liated physicians. Payment for such services shall become due and owing when the services are rendered, and the undersigned agrees to be liable for the payment for the services, provided that / MRHS dba Munroe Professional Services shall attempt to obtain payment for any such services from the insurance or employee benefi t program before attempting to obtain payment directly from the undersigned. This agreement is made solely for the protection of MRHS dba Munroe Professional Services and its affi liated physician group(s) in consideration for MRHS dba Munroe Professional Services’ administration of the undersigned’s insurance claims. The undersigned further understand and agree that my/our obligation to pay is not contingent on any settlement, judgment, or verdict which the undersigned may eventually recover from any third party, and that payment is due and must be paid by the undersigned upon demand by MRHS dba Munroe Professional Services. I/we recognize if the account becomes delinquent, I/we will be responsible for all collections and legal fees, if appropriate.

CONSENT FOR MEDICAL TREATMENT

I voluntarily consent to medical treatment and diagnostic procedures provided by MRHS dba Munroe Professional Services, the physician group or groups and other medical personnel. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made as to the result of treatments or examinations. SIGNED: X PATIENT DATE

SIGNED: X SPOUSE or OTHER THAN PATIENT DATE

If the PATIENT is unable to sign, state reason:

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2A

MRHS dba Munroe Professional Services physicians and staff look forward to serving and providing you professional, nurturing care. Our goal is to provide the fi nest-quality service to you, our patient. The information below will familiarize you with Munroe Surgery Program’s billing and collection policies.

Please complete and bring the signed copy with you.

Insurance Billing Policy As a courtesy, MRHS dba Munroe Professional Services will fi le your medical claims with both primary and secondary insurance. However, contact with your secondary insurance, beyond billing, is your responsibility. If your secondary insurance fails to remit payment in a timely manner, the balance becomes your responsibility. Once charges become your responsibility, this is refl ected on your monthly statement as “Total Due From Patient” and is due and payable upon receipt. If, for any reason, an insurance payment is received for services you previously paid, a refund to you, the patient, will be issued.

Attention: This practice is a Provider-Based entity which operates as an outpatient department of Munroe Regional Medical Center. You may receive a separate bill for the services provided to you from Munroe Regional Medical Center. Patient Counselors are available to provide you with detailed information concerning your account. Should you have any questions, please contact OSA at Munroe Regional Medical Center Accounts Receivable Department by calling 1-678-839-4390.

Uninsured Accounts The NFV, Admitting, and Patient Accounting staff will function as fi nancial counselors in educating and informing patients of our discounts, charity and assistance programs. NFV and the charity offi ce will assist patients in completing their applications for the assistance programs. A prompt pay discount may be applied to all self-pay accounts paid within 10 business days of service.

Payment PolicyYou are responsible for any unmet deductible or co-pay amount at the time services are rendered. Once primary insurance processes your medical claim, the balance remaining is billed to your secondary insurance carrier, if applicable. If you are not covered by secondary insurance or your secondary insurance carrier does not remit timely payment, the balance becomes patient responsibility and must be paid in full within 90 days. The following forms of payment are accepted: personal check, money order, cash, or credit card (VISA/MasterCard/American Express/Discover). Note: If, for any reason, an insurance payment is mailed directly to you for services rendered by the physicians of MRHS dba Munroe Professional Services, the check and explanation of benefi ts must be forwarded to our offi ce immediately.

Authorization or Pre-certifi cation IF YOUR INSURANCE CARRIER REQUIRES AUTHORIZATION OR PRE-CERTIFICATION, IT IS IMPERATIVE YOU CONTACT YOUR INSURANCE COMPANY PRIOR TO YOUR OFFICE APPOINTMENT OR PROCEDURE TO OBTAIN AN AUTHORIZATION NUMBER. Once your insurance carrier responds with an authorization number, you must inform our offi ce for proper notation on your account. Your assistance with this process eliminates unnecessary delay in claim submission and payment. Claims submitted without proper authorization and/or pre-certifi cation can result in reduced payment, increased patient co-payments and claim denials.

I, the undersigned patient and/or subscriber, agree to comply with the policies and procedures of MRHS dba Munroe Professional Services and its affi liated physicians.

Patient Signature Date

Spouse / Subscriber / Authorized Agent Date

1541 SW 1st Avenue Suite 105 / Ocala, FL 34471Patient billing inquiries should be directed to Phone: 352-622-8152 Fax: 352-622-4408


1541 SW 1st Avenue Suite 105Ocala, FL 34471

Phone: 352-622-8152 Fax: 352-622-4408

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3A

MRHS DBA MUNROE PROFESSIONAL SERVICESPATIENT AUTHORIZATION TO THE USE AND DISCLOSURE OF PROTECTED

HEALTH INFORMATION (PHI) FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS

I, _______________________, understand that as part of my healthcare, The Practice originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment, • A means of communication among the many health professionals who contribute to my care, • A source of information for applying my diagnosis and surgical information to my bill • A means by which a third-party payer can verify that services billed were actually provided, and • A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

• The right to review the notice prior to signing this consent, • The right to object to the use of my health information for directory purposes, and • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations

I understand that the practice is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that The Practice reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should the practice change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or, if I agree, email).

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Phone: 352-622-8152 Fax: 352-622-4408

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3B

I wish to have the following restrictions to the use or disclosure of my health information:

You may release my PHI to:{ } Family Member(s) (enter relationship): { } Leave messages on my answering device: { } Other:

I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.

I fully understand and accept / decline the terms of this consent.

Patient’s Signature

Date

FOR OFFICE USE ONLY{ } Consent received by

on

{ } Consent refused by patient, and treatment refused as permitted{ } Consent added to the patient’s medical record on .

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Phone: 352-622-8152 Fax: 352-622-4408

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4A

MEDICARE SECONDARY PAYOR QUESTIONNAIRE

**IF YOU ARE ON DISABILITY OR ARE ELIGIBLE FOR MEDICARE THIS FORM MUST BE COMPLETED.**

1. Are you receiving Black Lung (BL) Benefi ts? _____Yes _____No If yes, date the benefi ts began ________________

2. Are the services to be paid by a Government Research Program? _____Yes _____No

3. Has the Department of Veterans Affairs (DVA) authorized and agreed to pay for your care at this facility? _____Yes _____No

4. Was the illness/injury due to work-related accident/condition? _____Yes_____No If yes, date of injury/illness__________________ Name of address of workers’ compensation (WC) plan:

5. Was illness/injury due to a non-work-related accident? _____Yes _____No If yes, date of accident _________________

6. Is no-fault insurance available (No-fault may pay for health care services resulting from injury to you regardless of who is at fault for causing the accident.) _____Yes _____No Name and address of no-fault insurer(S) and no-fault insurance policy owner: Insurance claim number(s)

7. Is liability insurance available? (Liability insurance protects against claims based on negligence, inappropriate action or inaction, which results in injury.) _____Yes _____No Name and address of liability insurer(s) and responsible party: 8. Are you entitled to Medicare based on: _____Age or _____Disability? What is your retirement date? ____________ (Required) What is your disability date? __________(Required) End-Stage Renal Disease (ERSD). If yes, please see receptionist for more questions.

9. Are you an organ donor? _____Yes _____No

10. Do you have a living will or advance directive? _____Yes _____No



Phone: 352-622-8152 Fax: 352-622-4408

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MEDICATION RECORD (Do not scan)Patient Name: First Middle Initial Last

Please list all medications, including supplements, and over the counter medications.**Also, please bring medications to your offi ce visits.**

Allergies:

Preferred Pharmacy________________________ Pharmacy Phone#

Pharmacy Address__________________________________________

Medication Strength/Dose

How do youtake it? Medication Strength/

DoseHow do you

take it?

S = Single Course√ = Current Medication x = Discontinued

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