INFORMACIÓN DEMOGRÁFICA DEL PACIENTE

Transcripción

1 INFORMACIÓN DEMOGRÁFICA DEL PACIENTE Apellido: Nombre: Inicial: Dirección: Apt: Ciudad: Estado: Código postal: Tel. de linea: ( ) Celular: ( ) Tel. Laboral: ( ) Sexo: F M Edad: Fecha de Nacimiento.: Núm. Seguridad Social: Estado Civil: Ocupación: Contacto de emergencia: Parentesco: Teléfono: ( ) Médico de atención primaria: Tel.: ( ) Nombre del empleador: A quien podemos agradecer por la referencia? INFORMACIÓN DE LA ASEGURADORA Indique que tipo de seguro Usted tiene. Tambien, puesta nos una copia de sus tarjetas de seguro, el nombre del abogado u otro que corresponda en su caso: Medicare Private Tricare Medicaid Workman s Compensation Automobile Accident Third Party Liability Crime Victim s Fund Por mi seguridad, prometo contestar este cuestionario de salud en su totalidad con información veraz. Firma: Fecha: 1

2 Financial Policy: I request and consent to an evaluation and treatment by BPS and Dr. Mark Domanski. I wish to rely on Dr. Domanski to exercise judgment for the best interest for myself or that of my dependent, the above named patient, during the course of treatment. I intend this consent to cover the entire course of treatment. I certify that I, and/or my dependent(s), have insurance coverage with the insurance company I provided and assign directly to BPS all insurance benefits, if any, otherwise payable to me, for services rendered. I authorize payment directly to BPS, the amount due from my insurance company for services rendered. Initials: Initials: Initials: I understand and agree that all services rendered to me or to my dependent are my responsibility, are to be charged directly to me, and that I am personally responsible for full payment. I authorize the use of my signature on all insurance submissions. I acknowledge that I will be held responsible for any and all collection expenses incurred including a 30% attorney fee on any balance referred to any attorney for collection as a result from my delay in payment. I acknowledge that Dr. Domanski and BPS do NOT participate directly with any insurance company or managed-care plans (except Medicare). Since BPS is a non-participating plan provider, payment for these services may be mailed directly to the patient. If I receive a check, I will immediately remit payment to Bluemont Plastic Surgery, P.C. I can endorse the insurance check by writing Pay to the Order of Bluemont Plastic Surgery" on the back and sign my name directly below. I will mail the check, together with any insurance correspondence, Explanation of Benefits (EOB), to Bluemont Plastic Surgery. I understand that my cooperation may be required to assist the office with appealing and reprocessing my insurance claims. I authorize this office to file a grievence/appeal on my behalf for all services rendered. Mark Domanski, M.D. and BPS may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. If the service was paid for via credit card, debit card, or check, BPS may use my health care information and may disclose such information to my credit card, debit card, or bank, which I provided, for the purpose of obtaining payment for services rendered. I agree to waive any and all chargeback rights or claims for any amounts paid for by credit card or debit card. In respect for other people s time, if I am unable to keep my office appointment, I will either give 24 hours notice or I will be subject to a charge of $80 at BPS s sole discretion. Name: Signature: Date: 2

3 Cómo podemos ayudarle? Si su visita es sobre una herida despues de un accidente, por favor incluya FECHA del accidente. Historial médico: Tiene usted o ha tenido alguno de los siguientes problemas o enfermedades? problemas con la anestesia artritis asma trastornos de coagulación trastornos en la sangre cáncer herpes labial trombosis venosa profunda depresión diabetes epilepsia enfermedad gastrointestinal ataque cardíaco problemas del corazón hepatitis alta presión sanguínea VIH enfermedad del riñón alergia al látex enfermedad del higado enfermedad pulmonar embolia pulmonar problemas de salud mental abortos involuntarios apnea del sueño accidente cerebrovascular ulceras estomacales problemas de tiroides tuberculosis problemas de cicatrización de heridas Ha sido admitido en el hospital alguna vez?, motivo? Historial médico familiar: Sus familiares de primer grado (padres, hermanos, hijos) han tenido algunos de los siguientes problemas o enfermedades? Medicamentos: Toma ibuprofeno o aspirina de forma regular? Sí No (Estos medicamentos aumentan el riesgo de sangrado) Incluya TODOS los medicamentos y suplementos herbales (vitaminas, hierbas, pastillas para dormir, etc,) Medicación Dosificación Motivo por el cual lo toma Si Usted toma más de 3 medicamentos, escriba "Ver lista" y puesta nos su lista de medicamentos. Tiene alergias a algún medicamento? Qué reacciones ha tenido? Medicación Reacción Si Usted tiene más de 2 medicamentos, escriba "Ver lista" y puesta nos su lista de alergias. 3

4 Historia quirúrgica: (incluir procedimientos cosméticos y dentales): Fecha: Fecha: Fecha: Historia social: Fuma, consume tabaco o productos con nicotina? Cuántos paquetes por día? Hace cuantos años? Si ha dejado de fumar, hace cuanto dejó Fecha Consume alcohol? Ha tenido alguna vez problemas con el alcohol como un DUI (beber bajo la influencia del alcohol? Se ha inyectado alguna vez una droga recreativa? Que es su ejercicio favorito? Altura Peso: Su peso, ha sido estable durante los últimos seis meses? Para los Pacientes Femeninas piensando sobre cirugía o inyecciones. Está o podría estar embarazada? Está amamantando? Utiliza algún método anticonceptivo? Qué tipo? Tiene hijos? Número de embarazos? Está considerando tener más hijos? Si se ha realizado mamografías, cuándo fue la última? Hay algo en su historial médico que no figuran en este formulario que considere de importancia médica? 4

5 Por razones legales, esto necesita ser en inglés. A picture for a plastic surgeon is like an X-ray for a bone surgeon. Your privacy is important, so we have a written policy. Photo-documentation and Communication policy: I consent to the taking of photos or video footage of me or parts of my body in connection with the past or future care provided by Bluemont Plastic Surgery, P.C. ( BPS ). I provide this authorization as a voluntary contribution in the interests of my medical care and public education. For example, photo documentation can help me better understand my healing process. I understand that such photographs will be retained by BPS and may be released for the limited purpose of including them in any print, visual or electronic media, specifically including, but not limited to, medical journals and textbooks, advertising, for the purpose of informing the medical profession or the general public about plastic surgery procedures and methods. I also grant permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery, Inc. (ABPS). I understand that information disclosed, or some portion thereof, may be protected by state law and/or the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). I further understand that, because ABPS is not receiving the information in the capacity of a health care provider or health plan covered by HIPAA, the information described above may no longer be protected by HIPAA. Neither I, nor any member of my family, will be identified by name in any publication. I understand that in some circumstances the images may portray features that will make my identity recognizable. I understand that I may refuse to sign this authorization and such refusal will have no effect on the medical treatment I receive from my provider. However, forgoing the benefit of photo-documentation may make tracking and understanding my healing more difficult. I understand that I have the right to revoke this authorization in writing at any time, but if I do so it won't have any affect on any actions taken prior to my revocation. If I do not revoke this authorization, it will expire 35 (thirty-five) years from the date written below. I release and discharge Dr. Domanski, BPS, and all parties acting under their license and authority from all rights that I may have in the photographs and from any claim that I may have relating to such use in publication, including any claim for payment in connection with distribution or publication of the photographs. If computer imaging is used in my evaluation, I understand that the alteration is purely for the purpose of illustration and discussion and in no way constitutes an expressed or implied warranty as to my final results and appearance. There are many ways to communicate with you. It is important to keep appointments and let us know if problems or issues arise. Methods of communicating are by telephone, text, social media, pager, answering service if available, , and regular mail. If an emergency arises, keep us alerted to your progress so we may aid in any necessary treatments. Please do not leave a message (or send s) after hours or on weekends on the office answering machine if any urgent or emergent situation exists, as there is a delay in retrieving such messages. All attempts will be made to preserve your privacy in accordance with HIPAA rules. I certify that I have read the above Authorization and Release, fully understand, and agree to its terms. Nombre: Firma: Fecha: 5

6 Notice Of Privacy Practices This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect on 10/1/2015 and will remain in effect until it is amended or replaced by us. It is our right to change our privacy practices provided law permits the changes. Before we make a significant change, this Notice will be amended to reflect the changes and we will make the new Notice available upon request. We reserve the right to make any changes in our privacy practices and the terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made. You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer, Mark Domanski, M.D. Information on contacting us can be found at the end of this Notice. Typical Uses And Disclosures Of Health Information: We will keep your information confidential, using it only for the following purposes: Treatment: We must use your health information to provide you with our professional services. We have established minimum necessary or need to know standards that limit various staff members access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement. Disclosure: We may disclose and/or share your healthcare information with other health care professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so. Payment: We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves our business office staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances. Emergencies: We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of emergency involving your care, your location, your general condition or death. If at all possible we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are incapacitated we will use our professional judgment to disclose only that information directly relevant to your care. We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x rays, or other similar forms of health information and/or supplies unless you have advised us otherwise. Healthcare Operations: We will use and disclose your health information to keep our practice operable. Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities. Required by Law: We may use or disclose your health information when we are required to do so by law. (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others. Public Health Responsibilities: We will disclose your health information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability. Marketing Health-Related Services: We will not use your health information for marketing purposes unless we have your written authorization to do so. National Security: The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voice messages, text messages, s, postcards or letters. Access: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Office for a copy of the Request Form. You may also request access by sending us a letter to the address at the end of this Notice. Once approved, an appointment can be made to review your records. Copies, if requested, will charged in accordance to state law. If you want the copies mailed to you, postage will be charged. If you prefer a summary or an explanation of your health information, we will provide it for a fee. Please contact our Privacy Officer for a fee and/or for an explanation of our fee structure. Amendment: You have the right to amend your healthcare information if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied. Non-routine Disclosures: You have the right to receive a list of non-routine disclosures we have made of your health care information. (When we make a routine disclosure of your information to a professional for treatment and/or payment purposes, we do not keep a record of routine disclosures: therefore these are not available.) You have a right to a list of instances in which we, or our business associates, disclosed information for reasons other than treatment, payment or healthcare operations. You can request non-routine disclosures going back 6 years starting April 14, Information prior to that date would not have to be released. (Example: If you request information on May 15, 2004, the disclosure period would start on April 14, 2003 up to May 15, Disclosures prior to April 14, 2003 do not have to be made available.) Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We do not have to agree to theses additional restrictions, but if we do, we will abide by our agreement (except in emergencies.) Please contact our Privacy Officer if you want to further restrict access to your health care information. This request must be submitted in writing. QUESTIONS AND COMPLAINTS You have a right to file a complaint with us if you feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us in writing. Request a Complaint form from our Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. This form does not constitute legal advice and covers only federal, not state, law. Bluemont Plastic Surgery, P.C Arlington Blvd, Ste 410 Fairfax, VA I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. Name: Signature: Date: 6