Registro de nuevos pacientes

Date*
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PATIENT DEMOGRAPHICS
Name*
Nombre Apellidos
Address*
Dirección Dirección 2 Ciudad Estado / Provincia / Región ZIP / Código Postal
Date of Birth*
MM barra DD barra AAAA
Home Phone
Mobile Phone
Email
Emergency Contact (Next of Kin)
Emergency Contact Phone
Relation to Emergency Contact
Primary Physician
Preferred Pharmacy and Address
How did you hear about us?*
- Web Search / Google / www.sfveincenter.com
- Yelp
- I came from a doctor or a hospital
Referring doctor or hospital
Insurance Card
This link will allow you to use your mobile phone to capture the front and back of your insurance card/s. Desktop computers will require you to upload an existing image.

If you have trouble uploading, you may skip this step but be sure to bring your insurance card/s to your appointment.

Be sure to capture the front and back of the card/s.
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PATIENT MEDICAL HISTORY
Reason for visit*
Please list any medical conditions you have. For example: high blood pressure, diabetes, varicose veins, etc.
Please list any hospitalizations or surgeries you have had in the past. Please include approximate date and hospital
Do you take any medications?*
- No
- Yes - I will bring a list of my medications to the office.
- Yes - I can enter my medications now
Please list medications you take. (Name, Quantity, Frequency). If you have too many to write, please be sure to bring us an accurate list at the office.
Please list any medical conditions that run in your family.
Please list any allergies you have if any
Have you ever smoked?*
- Yes
- No
How many packs per day?*
How many years did you smoke?*
Have you stopped?*
- Yes
- No
When did you stop*
How many alcoholic drinks do you have per day*
Have you ever had a problem with alcohol*
- Yes
- No
What do you do for work?

Patient Financial Responsibility Agreement

Cancellation policy

While we understand there may be times when you miss an appointment due to emergencies or obligations, we enforce the following cancellation policy:
- We require at least a 48 hour (2 business days) notice to cancel an office appointment. A $75 fee will be charged for cancellations made less than 48 hours (2 business days) from the appointment time or missed appointments
- We require at least a 72 hour notice (3 business days) to cancel a procedure. A $250 fee will be charged for cancellations made less than 48 hours from the procedure time or if the procedure is missed. Procedures require special preparation of equipment and a procedure room which is reserved.
General responsibilities

You (or patient’s guardian) are responsible for the payment of your treatment and care.

Insurance
- Your insurance policy is a contract between you and your insurance provider. You are responsible for understanding and paying your insurance copays, deductibles, and coinsurance. Our staff is happy to explain what these are if you need help.
- As a curtesy, we bill your insurance company for you and charge you copays, deductibles, and/or coinsurance as instructed by your insurance company.
- As a curtesy, we try to verify coverage and eligibility. However, it is your responsibility to determine if the doctor is in-network prior to being seen.
- You are responsible for providing us with the most correct and updated information about your insurance.
- You are responsible for any amounts not covered by insurance.
We are committed to providing you with the best possible care. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions. We are pleased to discuss our financial policy with you at any time.

I have read, understand and agree to the provisions of this Patient Financial Responsibility Form. In the event of nonpayment or default, I am responsible for all costs and reasonable collection and/or attorney fees.
Signature*
Name*
Date
MM barra DD barra AAAA

Patient Health Information Authorization Agreement and Consent

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we require you to read and sign this form stating that you understand and agree with how your health information will be used, your authorization to use that information, and your rights regarding that information.

Notice of Privacy Practices

I acknowledge that I have been provided with this office's Notice of Privacy Practices. I understand that it provides a complete description of the uses and disclosures of my health information. I understand that a copy of the Notice of Privacy Practices is also available at the front desk as well as https://www.sfveincenter.com.

Authorization for the Disclosure of PHI for Treatment, Payment, or Healthcare Operations

I understand that as part of my healthcare this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, 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 health professionals who may contribute to my healthcare.
- 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.
- a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I authorize the disclosure of my Protected Health Information as specified above.

Consent to the Use and Disclosure of PHI for Treatment, Payment, or Healthcare Operations

I understand that:
- I have the right to review this facility's Notice of Information practices prior to signing this consent.
- This facility, reserves the right to change the notice and practices.
- I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested.
- I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.
- It is this facility's procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.
Open Payments Database

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.
Signature*
Name*
Date
MM barra DD barra AAAA
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Registro de nuevos pacientes

Paso 1 de 5

PATIENT DEMOGRAPHICS

PATIENT MEDICAL HISTORY

Patient Medical History - Review of Systems

Patient Financial Responsibility Agreement

Patient Health Information Authorization Agreement and Consent