EL PASO RESPIRATORY & SLEEP CONSULTANTS

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Lucas Alvarado Ayala
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1 NEW EL PASO RESPIRATORY & SLEEP CONSULTANTS UPDATE PATIENT REGISTRATION Patient Information (*Required) First Name* MI Last Name* Sex Male Female Address* Apt. City* State* Zip Code* Telephone Number* Mobile or Alternative Number* Age* ( ) ( ) Date of Birth* Social Security Number* Single Married Widow Other Primary Insurance (All Fields Required) Medicare Medicaid BC/BS Tricare Bienvivir Other: ID Number Group Number Insured s Name Relationship to Patient Self Child Spouse Other Social Security Number Date of Birth Secondary Insurance (If Any) (All Fields Required) Medicare Medicaid BC/BS Tricare Bienvivir Other: ID Number Group Number Insured s Name Relationship to Patient Self Child Spouse Other Social Security Number Date of Birth Primary Care Physician: 1. Is your spouse or other family member employed? YES NO 2. Do you have a Secondary insurance policy? YES NO 3. Are you covered under an employer or union policy? YES NO 4. Are you currently employed? YES NO 5. Did you sustain an injury at work? YES NO 6. Are your injuries accident related? YES NO Who will be responsible for this bill? Referred by: * Reason for Visit:* Emergency Contact:* Telephone Number* Relationship* ( ) Release and Assignment (Must Be Signed and Dated!) I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional service rendered. I have read all the information on both sides of the this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my status or the above information. I authorize release of any information necessary to process my insurance claims and assign and request payment directly to El Paso Respiratory & Sleep Consultants. Sign: Date:

2 El Paso Respiratory & Sleep Consultants Erasto Cortes, MD, FCCP, FAASM Hernando Garcia, MD, FCCP Adriana Sanchez, ACNP 1020 Montana Ave. El Paso, TX Telephone: (915) Fax: (915) CONSENT FOR CARE I hereby give my consent for treatment to El Paso Respiratory & Sleep Consultants. Please Date and Initial that you have read the following statements and that you give Consent to each one. AUTHORIZATION TO OBTAIN / RELEASE MEDICAL RECORDS I authorize El Paso Respiratory & Sleep Consultants or any person designated by them, to obtain/release copies of my medical records to any entity, physician or institution for the purpose of evaluation and/or comparison with examination and testing being performed on my self (this may include medical, social, psychiatric, drug or an alcohol abuse, AIDS/HIV related information). I understand I have the right to review a Notice of the uses and disclosure of my health information. I may revoke this consent at any time. Date: Initial: AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN I hereby authorize Medicare/Medicaid and/or other insurance company to pay any or all benefits and/or payments to El Paso Respiratory & Sleep Consultants, for services rendered to me or my dependents. I also authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for any balance not covered by my insurance including screening test and other exams and/or collection cost and legal fees incurred in an attempt to collect said balance. Date: Initial: AUTHORIZATION TO LEAVE MESSAGE I hereby authorize my physician s office to leave a message regarding pending appointments and/or tests and results at my residence either on answering machine, voice mail, and at home, office. Date: Initial: I have been given a copy of the privacy notice of the practice required by HIPPA. Signature of Patient or Personal Representative Date

3 El Paso Respiratory & Sleep Consultants Erasto Cortes, MD, FCCP, FAASM Hernando Garcia, MD, FCCP Adriana Sanchez, ACNP 1020 Montana Avenue El Paso, TX Telephone: (915) Fax: (915) NOTICE TO PATIENT Since you will be under the care of one of our doctors or our nurse practitioner, you do need to be aware of the following information: If for any unfortunate reason you were to be hospitalized and your regular doctor from our office is not on call at the hospital that you are at, you will be seen by the doctor on call from our association for that particular hospital. Please note that our doctors do rotations all year long and will not be able to see you unless he is on call at that specific hospital at specific time. We do apologize for the inconvenience and hope you can understand. Ya que usted va estar bajo el cuidado de uno de nuestros doctores o nuestra Enfermera usted necesita estar enterado de la siguiente información. Si por cualquier motivo fuera usted imternado en el hospital y su doctor regular de nuestra ASOCIACION no puediera atenderlo. Uno de los doctores que pertenecen a la asociacion, lo atendera. Tenga en cosideracion que nuestros doctores hacen rotaciones durante todo el transcuro del ano y su doctor no podra verlo a menos de que el este de guardia en ese hospital en particular. Nos disculpamos por la inconveniencia y esperamos que usted pueda entender. Name (Print) /Nombre (Molde) Signature/Firma Date/Fecha

4 El Paso Respiratory & Sleep Consultants Erasto Cortes, MD, FCCP, FAASM Hernando García, MD, FCCP Adriana P. Sánchez, ACNP 1020 Montana Avenue El Paso, TX Telephone: (915) Fax: (915) CANCELLATION FEE As of January 1, 2012, any appointment not cancelled within 24 hours of appointment will be charged a $25.00 fee. The patient will be responsible for this fee and will not be billed to the insurance. The fee will be due prior to next appointment. Signature Date CARGO DE CANCELACION A partir del 1ro de enero de 2012, cualquier cita que no sea cancelada con 24 horas de anticipación tendrá un cargo de $25.00 dls. El paciente será responsable por este cargo y no la aseguranza. El honorario será debido antes de próxima cita. Firma Fecha

5 Instructions for Medication List Write the name of each medication you take, the reason, the dose, time, etc. In the last column, write special instructions such as with food, etc. Include over- the- counter medications such as vitamins, nutritional supplements, pain relievers, antacids, laxatives and/or herbal remedies. Carry this list with you for the day of your appointment. Add new medications when you start taking them. Medication List Patient: D.O.B.: Prescription/Medication Purpose or Reason Taken Dose Time(s) of Day Form(Liquid, Capsule, Tablet) Special Instructions

6 Primary Physician: Drug Allergies: Pharmacy: Pharmacy Number:

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