Adrian J. Finol, M.D. P.A. Farhaad C. Golkar M.D. P.A...

Adrian J. Finol, M.D. P.A. Farhaad C. Golkar M.D. P.A.

PATIENT INFORMATION SHEET

Last Name: First Name: M.I. DOB:

Home Address:

City: State: Zip Code: +

EMAIL:

Mailing/Secondary Address(if different from above)


Home Phone: Cell Phone: Work Phone:

Social Security Number: Marital Status: Gender:

Emergency Contact: Relationship:

Zip Code: Home Phone: Primary Care Provider:

Other physicians who would like a copy of today's visit notes:

Preferred Pharmacy: Pharmacy Phone:

Primary Insurance: Insurance ID#:

Group#: Effective Date:

Secondary Insurance: Insured's Name:

Secondary ID# Group#:

If you are not the primary insured then please complete the following

Primary Insured's Name: DOB:

SSN of Primary Insured: Gender:

Address:


Relationship: Home Phone:

X SIGNATURE OF PATIENT OR RESPONSIBLE PERSON DATE

Print Name:

920 Rolling Acres Road | Suite 201 Lady Lake, FL 32159

Phone: 352.775.4833 Fax: 352.775.4839

_________________ _________________ _________________

________________

_____________________________________

_______ __________ _________

________________________________

___________________

_______ __________ _________

_____________________ ___________________ __________________

_________________ ___________ ___________________________________ __________________

_______________________________Home Address:

City: ________________ Referring Doctor:

_________State: ________ ___________________

________________________ ________________________________

___________________________________________________________________

________________________

____________________________

____________________________

___________________________

____________________________________________________

______________________________ _________________________________

_________________________ ___________________

_________________________ _______________________________________________________

_______________________ ____________ ___________ ____________

________________________ _______________________

_______________________________________________________ _________________________

____________________________________________________


PATIENT HISTORY FORM (1 of 3)

DATE OF APPOINTMENT AGE

LAST NAME FIRST NAME MI

CHIEF COMPLAINT (Why are you here today)

Date of onset

MAJOR ILLNESSES:1.

2.

3.

4.

5.

6.

7.

8.

LIST ALL SURGERIES (Operations, Year, Hospital, Surgeon) 1.

2.

3.

Yes No If yes what were they

4.

5.

Where your surgeries done under local/general anesthesia? If so, were there any complications? Yes No

Current Medication:

1.

2.

3.

6.

7.

8.

Primary Care Provider Referring Doctor

Cardiologist Pulmonologist

Gastroenterologist

Are you currently taking: Aspirin Plavix Eliquis Pradaxa Xarelto Warfarin Coumadin

Please list: Are you allergic to any medication? Yes No

Are you allergic to any food? Yes No Please list:920 Rolling Acres Road | Suite 201

Lady Lake, FL 32159 Phone: 352.775.4833 Fax: 352.775.4839

4.

5.

9.

10.

Check those that apply: Are you on blood thinners? Yes No

______________________ __________________

_________________________________ _________________ ________

____________________________________________________

_____________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

__________________________________________________________________________________

__________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________

_______________________________________ _______________________________________

_______________________________________

_______________________________________

______________________________________________________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

__________________________ __________________________

____________________________________________________

__________________________

____________________________________________________________________

____________________


PATIENT HISTORY FORM (2 of 3)Please Check Yes or No:

GASTROINTESTINAL SYSTEM REVIEW: HEAD AND NECK AREA:Abdominal Pain Yes No Nausea/Vomiting Yes No Vomit Blood Yes No Blood in stool Yes No Difficulty swallowing Yes No Heart Burn Yes No

Vision changes Headaches Nose Bleeds Thyroid Problem Change in Taste Change in Smell

Yes No Yes No Yes No Yes No Yes No Yes No

URINARY SYSTEM REVIEW: FAMILY HISTORY REVIEWDifficulty urinating Frequent Urination Painful Urination Blood in Urine Renal Failure

Yes No Yes No Yes No Yes No Yes No

Father: Mother: Sister(s): Brother(s):

SKIN: Rashes Yes No Skin Cancer Yes No Change in a Mole Yes No

PSYCHIATRIC Depression Yes No Anxiety Yes No Mood Swings Yes No

IMMUNE SYSTEM Swollen Lymph Nodes Yes No Leukemia / Lymphona Yes No

BLOOD SYSTEM REVIEW Anemia Yes No Easy Bruising Yes No Clotting Problems Yes No Blood Clots in Legs Yes No

GENERAL HEALTH Weight Loss Night Sweats Fever/Chills

Use of Tobacco Non-Smoker/Never smoked Tobacco Former Smoker/Quit Months/Years ago Current Smoker/ I smoke____ Cigarettes/

Packs a Day. Use of Alcohol:

I never use Alcohol I occasionally use alcohol. Approx. Drink(s) Per Week

I am a regular user of Alcohol. Approx. Drink(s) per day.

Use of Drugs I never use Drugs. I only use doctor prescribed medication. I use drugs recreationally. Please List:


Phone: 352.775.4833 Fax: 352.775.4839

________________________________________________________________________________________________________________________

__________________________________________________________________________________________

_________________________________________

______

______

_________

____________


PATIENT HISTORY FORM (3 of 3)

Please check any of the following problems you are currently having:

CARDIOVASCULAR SYSTEM REVIEW: Chest Pain Yes No Heart Attack Yes No High Blood Pressure Yes No Irregular Heart Rate Yes No Palpations Yes No Swelling in Ankles Yes No Heart Failure Yes No Last EKG? Result?

LOWER EXTREMITIES Pain in: Feet Calf Ankles

Worse with Ambulation Yes No Swelling of Ankles Yes No Visible/ Varicose Veins Yes No Numbness/ Tingling Legs/ Feet Yes No

NEUROLOGICAL SYSTEM REVIEW Tingling No Numbness Yes No Weakness Yes No

RESPIRATORY SYSTEM REVIEW Lung Problems Yes No Shortness of Breath Yes No Cough up Blood Yes No Wheezing/ Asthma Yes No

CAN WE RUN YOUR "RX" HISTORY? YES NO

Please sign to give permission:

X SIGNATURE OF PATIENT OR LEGAL GUARDIAN DATE

Print Name:


Phone: 352.775.4833 Fax: 352.775.4839

________ _________________

Yeses

____ ____ ____

______________________________________ _______________

______________________________________


OFFICE FINANCIAL POLICY

I. As a courtesy, we will file to your primary and secondary insurance. It is your responsibility to make sure that your insurance company has the most recent address and contact information.

II. We are required to make a copy of your insurance cards for verification purposes. It is your responsibility to notify our office if there have been any changes to your insurance.

III. We will collect your deductible, copayment, and uncovered service fees at the time of service. Accepted payment methods are: Cash, Check, MasterCard, Visa, and Discover Card.

IV. There is a $25.00 charge on all returned checks.V. Your insurance will send you an explanation of benefits that explains what they have paid to our office and

what your responsibility is. This is a record that you MUST keep on file. If you do not agree with their payment, please contact your insurance company directly.

VI. If payment is not received within 30 days of the filing date with your insurance, you will be notified that payment is due.

VII. Any unpaid charges may be turned over to a collection agency after ninety days. This would represent additional costs to you as you will be held responsible for any collection fees, legal fees, or court costs incurred in the collections process.

VIII. If you are sent outside of the office for additional testing such as lab work or imaging, that facility will file to your insurance for you. If you have questions regarding billing or claim payment, call the facility directly. We do not have information regarding billing from outside this office.

LIFETIME AUTHORIZATION FOR INSURANCE ASSIGNMENT'S AND AUTHORIZATION TO RELEASE INFORMATION

I. RELEASE OF INFORMATION- I, the below named patient, do hereby authorize any physician examining and/or treating me to release to any third payor (such as an insurance company or governmental agency, example: Blue Shield of Florida or Medicare) any medical condition and records concerning diagnosis and treatment when requested by such third party for its use in connection with determining a claim for payment for such treatment and/or diagnosis.

II. PHYSICIAN INSURANCE ASSIGNMENT- I, the below named subscriber, hereby authorize payment directly to any physician examining me of any group and/or individual surgical and/or medical benefits herein specified and otherwise payable to me for their services as described but not to exceed the reasonable and customary charge for their services.

III. MEDICARE/MEDICAID- Patient's certification authorization to release information and payment request, I certify that the information given by me in applying for payment under Title XVIII/XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to Social Security Administration/Division of Family Services or its intermediaries or carries any information needed for this of a related Medicare/Medicaid claim. I hereby certify all insurance pertaining to treatment shall be assigned to the physician treating me.

IV. I Permit A COPY OF THESE AUTHORIZATIONS AND ASSIGNMENTS TO BE USED IN PLACE OF THE ORIGINAL WHICH IS ON FILE AT THE PHYSICIANS OFFICE. This assignment will remain in effect until revoked by me in writing.

Please remember that insurance is considered a method of reimbursing the patient for fee paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. I understand it's my responsibility to pay the deductible amount, co-insurance, or any other balance not paid for by insurance or third payer within a reasonable period of time not to exceed 60 days.

If this account is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled to reasonable attorney's fees and costs of collection.


Print Name:


Phone: 352.775.4833 Fax: 352.775.4839

______________________________________

______________________________________ _______________


For Use of or Disclosure of Protected Health Information (PHI)

I, hereby authorize Adrian J. Finol, M.D. P.A., Farhaad C. Golkar, M.D. P.A. or his employees to ( ) release ( ) obtain copies of the medical records of

To/From:

Address

For the purpose of ( ) continued treatment ( ) Personal Records ( ) Other (please specify)

Date(s) of Service: From to

This authorization will expire on the following date, event, or condition . If I fail to specify an expiration event or condition, the authorization will expire in one year. I understand that this authorization is revocable upon written notice to the office where the original authorization is retained, except to except to the extent that action has already been taken on this authorization. Mental health, alcohol, drug, HIV and/or AIDS information of the undersigned, or as otherwise permitted by such regulations. I further request that no genetic counseling/testing information in my record be released without my written authorization, except as otherwise required by law. I understand that I may select the information from the list below to be released by placing my initials in the space provided. Furthermore, I understand that any disclosure of information from my records carries with it the potential for an unauthorized disclosure of my health information.

The specific records to be released or obtained. Please initial each item that applies.

Complete Record All diagnostic test results

Abstract of Record Pathology/Operative Reports

Consult/Progress Notes Therapy Records

Labs Only Radiology Only Other (please specify)


Print Name:

Social Security Number Date of Birth

Address Identification Shown

Witness Date


Phone: 352.775.4833 Fax: 352.775.4839

________________________

____________________________________________

____________________________________________

______________________________

____________ ____________________

__________

_____

_____

_____

_____

_____

_____

______________________________________

______________________________________

________________________________

________________________________

________________________

____________

____________

____________

____________

___


Use of a Surgical Assistant at Surgery

As deemed necessary by your surgeon, a surgical assistant or co-surgeon may be necessary to provide the highest level of care during a surgical procedure.

Surgical assistants are highly skilled and fully trained licensed and/or certified allied health professionals. Duties include, but are not limited to, identification of anatomical landmarks, securing blood vessels, recognizing pathological situations and providing and securing adequate, safe and proper exposure of the operative field, closure of the surgical wound, application of casts, dressings, etc., they also perform other duties delegated by the operating surgeon within the scope of their profession. As an integral part of the surgical team, surgical assistants contribute greatly to the safety and quality of the service provided patients every day.

The decision to utilize the services of a surgical assistant is solely the surgeon's. Your surgeon, after evaluating the surgical procedure and the level of technical involvement it requires, may deem it medically necessary to use the services of a surgical assistant. The issue of medical necessity is solely in the hands of the operating surgeon, he makes the decision with one objective in mind, and that is the highest quality of service to you and the safest way to perform the surgical procedure in the best possible environment.

Suzanne Dilley CSFA will be assisting me with your case in the operating room. Suzanne is highly trained and has extensive experience in General, Vascular and Thoracic surgery.

Suzanne Dilley will bill your health insurance for her assistance fees. All attempts will be made to work solely with your insurance provider to collect this fee. In some instances, health insurance companies could refuse to pay your claim or may apply it to your deductible. Should insurance deny your claim, there will be a flat fee of $100-$300Dr. A .

In these instances, you could be billed for the services provided by SMD Surgical Assisting, LLC. Mederi Services, LLC, will be the agency to contact you regarding the claim if needed. If you have any billing or insurance questions prior to your surgery you can contact a representative at Mederi Services, LLC.

Telephone: 877-563-3374 FAX: 866-730-5515 Email - [email protected]

Thank you,

Dr. A Finol and Dr. F Golkar

By signing this document you are stating that you have read the above material and understand.

X SIGNATURE OF PATIENT OR GUARANTOR DATE

Print Name:


Phone: 352.775.4833 Fax: 352.775.4839

____________________________________

______________________________________

__________

mailto:[email protected]


NOTICE OF PRIVACY PRACTICES (1 of 2)

At the office of Adrian J. Finol, M.D. P.A. and Farhaad C. Golkar, M.D. P.A., we are committed to treating and using protected health information about you responsibly. This notice of health information practices describes the persona information we collect, and how and when we use or disclose information. It also describes your rights as they relate to your protected health information. This notice is effective October 7th, 2014 and applies to all protected health information as defined by federal regulation

Understanding your health records/information: A record of your visit is made each time you visit our office. Typically, this record contains your symptoms, examination and test results, diagnoses, treatments, and a plan for future care or treatment. This information, often referred to as your health or medical records, serves as a:

• Basis for planning your care and treatment,• Means of communication among the many health professionals who contributes to you care,• Legal document describing the care you received,• Means by which you or a third-party payer can verify that services billed were actually provided,• A tool in educating health professionals,• A source of data for medical research• A source of information for public health officials charged with improving the health of this state and

the nation,• A source of data for planning and our marketing,• A tool with which we can assess and continually work to improve the care we render and the

outcomes we archive.Understanding what is your record and how your health information is used helps you to: ensure its accuracy, better understand who, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others. You have a right to receive notification of breaches of unsecured protected health information.

Your Health Information Rights: Although your health record is physical property of Farhaad C. Golkar M.D. P.A., the information belongs to you. You have the right to:

• Obtain a paper copy of this notice of information practices upon request• Inspect and copy your health record as provided for in 45 CFR 164.524,• Amend your health record as provided in 45 CFR 164.528,• Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528• Request communications of your health information by alternative means or at alternative locations,• Request a restriction of PHI regarding care and services you pay for out of pocket. Request must be in

writing and the provider will adhere to your request.• Request a copy of your health records is an electronic format if applicable,• Request a restriction on certain uses and disclosure of your information as provided by 45 CFR

164.522• Revoke your authorization to use or disclose health information except to the extent that action has

already been taken.

Our responsibilities: Adrian J. Finol, M.D. P.A. and Farhaad C. Golkar, M.D. P.A are required to: • Maintain the privacy of your health information• Provide you with this notice as to our legal duties and privacy practice with respect to information we

collect and Maintain about you,• Abide by the terms of this notice,


Phone: 352.775.4833 Fax: 352.775.4839


NOTICE OF PRIVACY PRACTICES (1 of 2)

• Notify you following a breach of unsecured PHI;• Notify you if we are unable to agree to a requested restriction, and• Accommodate reasonable requests you may have to communicate health information by alternative

means or an Alternative locations

We reserve the right to change our practices and make the new provisions effective for all protected health information we maintain. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.

Required Authorization: A written authorization is required from you for: • Disclosure of psychotherapy notes• Use of protected health information (PHI) in marketing• Sales of PHI

For more information or to report a problem: If you have a questions and would like additional information, you may contact the Practice’s Policy Officer Angie Ramos at 352-775-4833 If you believe your privacy rights has been violated, you can file a complaint with the Practice’s Privacy Officer, or with the Office of Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address or the OCR is: Office for Civil Rights, U.S. Department of Heath and Human Services, 200 Independence Avenue, S.W., Room 509f, HHH Building, Washington D.C. 20201


Phone: 352.775.4833 Fax: 352.775.4839


ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

PRIVACY POLICIES AND PROCEDURES

This Notice of Privacy Practices is made available to you via our website and in writing. Please fill out the document below.

I, have been offered a copy of Dr. Adrian J. Finol MD, PA's,

Dr. Farhaad C. Golkar MD PA's "Notice of Privacy Practices". This Notice describes in detail how my Protected

Health Information {PHI) maybe used or Disclosed by Dr. Adrian J. Final MD, PA's, Farhaad C. Golkar MD,

PA's, according to HIPAA regulations and further describes my rights under HIPAA.

I have been offered a copy of the Notice of Privacy Practices and acknowledge I have received a copy.

I have been offered a copy of the Notice of Privacy Practices and am DECLINING to accept a copy.

Your signature below documents that you have been offered the Notice of Privacy Practices.


Print Name:

X SIGNATURE OF AUTHORIZING REPRESENTATIVE DATE

Print Name:

( ) Patient or Authorized Representative refused to sign Acknowledgement.

Employee Initial's

Printed Name of Employee DATE


Phone: 352.775.4833 Fax: 352.775.4839

___________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

__________________

__________________

__________________

__________

Adrian J. Finol, M.D. P.A. Farhaad C. Golkar M.D. P.A...

Documents

Transcript of Adrian J. Finol, M.D. P.A. Farhaad C. Golkar M.D. P.A...