ࡱ> M H>bjbj== "WW#lttt8$<22 l`$"+1-1-1-1-1-1-1$3 6Q1$$$Q1,n2,,,$+1,$+1,,f.0+1  ȦNr t4$00+12020,6d%T6+1,<,Account #_____________________ DALLAS OTOLARYNGOLOGY ASSOCIATES Daniel M. Dansby, M. D. B. Robert Peters, M. D. REGISTRATION FORM PATIENT MUST BE ACCOMPANIED BY AN ADULT IF UNDER 18 PATIENT INFORMATION: Please print clearly Confidential Patient Information Todays Date:  FORMTEXT  DATE 6/9/20046/9/2004 Legal Name:  FORMTEXT       Age:  FORMTEXT       Birth Date: FORMTEXT       Sex:  FORMCHECKBOX M  FORMCHECKBOX  F Social Security #: FORMTEXT       Marital Status:  FORMCHECKBOX  S  FORMCHECKBOX M  FORMCHECKBOX  W  FORMCHECKBOX  D  FORMCHECKBOX Separated Address:  FORMTEXT       City:  FORMTEXT       State: FORMTEXT       Zip:  FORMTEXT       Home Phone:  FORMTEXT       Cell Phone:  FORMTEXT       TX Drivers License:  FORMTEXT       Work Phone: FORMTEXT       Employer:  FORMTEXT       E-Mail Address:  FORMTEXT       RESPONSIBLE PARTY INFORMATION (Policy Holder): Legal Name:  FORMTEXT       Age:  FORMTEXT       Birth Date: FORMTEXT       Sex:  FORMCHECKBOX M  FORMCHECKBOX  F Social Security #:  FORMTEXT       Marital Status:  FORMCHECKBOX  S  FORMCHECKBOX  M  FORMCHECKBOX  W  FORMCHECKBOX  D  FORMCHECKBOX Separated Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip  FORMTEXT       Home Phone:  FORMTEXT       Cell Phone: FORMTEXT       Work Phone:  FORMTEXT       Employer: FORMTEXT       E-Mail address  FORMTEXT       SPOUSE OR SECOND PARENT INFORMATION: Legal Name:  FORMTEXT       Age:  FORMTEXT       Birth Date: FORMTEXT       Sex:  FORMCHECKBOX M  FORMCHECKBOX  F Social Security #:  FORMTEXT       Marital Status:  FORMCHECKBOX  S  FORMCHECKBOX  M  FORMCHECKBOX  W  FORMCHECKBOX  D  FORMCHECKBOX Separated Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       Home Phone:  FORMTEXT       Cell Phone:  FORMTEXT       Work Phone:  FORMTEXT       Employer:  FORMTEXT       E-Mail address  FORMTEXT       NEAREST RELATIVE INFORMATION: Legal Name:  FORMTEXT       Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       Home Phone:  FORMTEXT       Work Phone:  FORMTEXT       INSURANCE INFORMATION: Primary Insurance Co.: FORMTEXT       I.D.#: FORMTEXT       Employer Group Name:  FORMTEXT       Group #: FORMTEXT       Insurance Claims Address:  FORMTEXT       Insurance Phone #:  FORMTEXT       Subscriber s Name:  FORMTEXT       Relation to Patient:  FORMTEXT       Place of Employment:  FORMTEXT       Secondary Insurance Co.:  FORMTEXT       I.D. #:  FORMTEXT       Employer Group Name:  FORMTEXT       Group #:  FORMTEXT       Insurance Claims Address:  FORMTEXT       Insurance Phone #:  FORMTEXT       Subscriber s Name:  FORMTEXT       Relation to Patient: FORMTEXT       Place of Employment: FORMTEXT       PLEASE PROVIDE US WITH ALL YOUR INSURANCE CARDS INCLUDING MEDICARE SO THAT WE MAY MAKE A COPY FOR YOUR FILE. Authorization to release information and assign benefits: I hereby authorize the release of any medical information in the processing of my claim. I also authorize payment directly to Dr. Dansby or Dr. Peters and Associates for the medical / surgical benefits. Signed:__________________________________________Date:_________________________ DALLAS OTOLARYNGOLOGY ASSOCIATES Ambulatory History Today s Date  FORMTEXT       Patient Name  FORMTEXT       Birth Date  FORMTEXT       Age  FORMTEXT       Pharmacy Name  FORMTEXT       Phone #  FORMTEXT       Whom may we thank for referring you?  FORMTEXT       Referring Physician or Practitioner  FORMTEXT       Why are you here today?  FORMTEXT       How long have you had this problem?  FORMTEXT       Past Medical History: Please list all medications you are presently taking, including over the counter, prescription, and any herbal medications  FORMTEXT       Allergies to Medications: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please List:  FORMTEXT       Allergic to Latex: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please List:  FORMTEXT       Previous Surgery: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please List:  FORMTEXT       Hospitalizations: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please List:  FORMTEXT       Tobacco (any form): No  FORMCHECKBOX  Yes  FORMCHECKBOX  Kind & Amount:  FORMTEXT       Alcohol: No  FORMCHECKBOX  Yes  FORMCHECKBOX  If yes, Occasional  FORMCHECKBOX  Moderate  FORMCHECKBOX  More than moderate  FORMCHECKBOX  Review of Medical Systems (Explain briefly if you answer yes to any of the following problems) Heart: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       Kidney or Bladder: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       Lung: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       Neurological/Stroke: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       Diabetes: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       Thyroid: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       High Blood Pressure: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       Bleeding Problems: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       Glaucoma: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       Stomach, intestine, liver, or bowel: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       Family History of bleeding problems: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       Cancer of any form: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       Any family history of problems with anesthesia: No  FORMCHECKBOX  Yes  FORMCHECKBOX  Please Explain:  FORMTEXT       FEMALES: Are you pregnant? Or suppose that you might be? No  FORMCHECKBOX  Yes  FORMCHECKBOX  Patient Signature (Parent, if minor) _________________________ Relation to patient __________ Physician Signature ____________________________________ Date _______________ Ambulatory history/my documents DALLAS OTOLARYNGOLOGY ASSOCIATES Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bills is considered a part of your treatment. The following is a statement of our financial policy, which we require you to read, agree to and sign prior to any treatment. Dr. Dansby and Dr. Peters render only services that, in their best professional judgment, are needed to provide quality medical care for you. PAYMENT IS DUE AT THE TIME OF SERVICE We accept cash, checks, Visa or MasterCard REGARDING INSURANCE Our office is pleased to assist you in filing claims with your insurance company for reimbursement of these expenses. We will wait 45 days for your insurance company to pay your claim and if they do not we will give you 30 days to pay the balance. The patient is responsible to pay any deductible and co-payments at the time services are rendered. It is your responsibility to know if a referral is necessary for your visit. Any portion of a billed amount that is labeled disallowed or not covered will become the patients responsibility. Our office NEVER guarantees that your insurance will pay. We will make every attempt at the beginning of your health care to receive verification of your policy benefits. However, if for some reason your insurance claim is denied, you are responsible for the amount due on your account. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. While we have an agreement with the Health Plan to provide services, any questions regarding coverage must be resolved by you with the insurance company. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. USUAL AND CUSTOMARY RATES Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance companys determination of usual and customary. NSF CHECKS All returned checks will be assessed a $25.00 fee. All returned checks not paid in 15 days will be filed with the proper authorities. Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. I have read, understand and agree to the provisions of this financial policy. 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