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ADULT REGISTRATION FORM

Maryland ENT logo

2415 Musgrove Road, Suite 203
Silver Spring, Maryland 20904
(301) 989-2300
 
 
Adult Patient Information
Gender*
 
At least one phone number below is required*
Allergies to any Medications?*
 
Insurance Information
Do you have Healthcare Insurance?*
Authorization

I hereby authorize Maryland ENT Associates to apply for benefits on my behalf for services rendered to me and request that payment be made by my insurance company and that payments be sent directly to Maryland ENT Associates. I understand that it is the policy of Maryland ENT Associates to only bill my insurance company if they participate with that company, and if they do not, it will be my responsibility to bill my insurance company for reimbursement of my expenses. I further authorize Maryland ENT Associates to release necessary information to my insurance company, or to the Insurance Commissioner of MD as necessary to obtain payment for my services.

I understand that this in no way relieves me of my primary responsibility to pay for services rendered to me, and if my account is turned over to an attorney for collection, I agree to pay any collection and reasonable legal fees (40% is deemed reasonable) court costs, and other expenses incurred as a result of said collection, all actions having a venue of Montgomery County, MD, other venues notwithstanding. Further, I understand that there is a $25.00 fee for returned checks and $50.00 for missed appointments.

I certify that the information I have reported with regard to my insurance coverage is correct and I authorize the release of any information relating to any claim for benefits, in order to process any claim for benefits. Furthermore, I permit a copy of this authorization to be used in place of the original. I may revoke this authorization at any time in writing.

I understand that the information contained on this form will be used to process my billing and/or insurance claims for service received in this office. It is important to be sure that this information is correct prior to receiving care to prevent problems for the patient in the future.

Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 

 

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ADULT MEDICAL HISTORY

 
Adult Patient Information
Demographics
Gender*
 
Ethnicity
 
Marital Status
     
General Health History
Are you ALLERGIC to any medications or Latex?*
 
Do you use blood thinners? Ex: aspirin, Coumadin/Warfarin, Plavix, Pradaxa?*
 
Do you use any herbal, alternative medications, or diet pills?*
 
Are you CURRENTLY taking any medication (prescription or non-prescription)?*
 
Health Problems
Please list any current or past health problems:
Cardiac (eg: cholesterol, pacemaker, heart attack*)
 
Hypertension or high blood pressure*
 
Diabetes or uncontrolled sugar*
 
Thyroid (eg: nodules, goiter, high or low function*)
 
Allergies or hay fever*
 
Hearing loss, ringing, or other hearing changes*
 
Sinus or nasal problems previously diagnosed*
 
Neurologic (eg: migraine, multiple sclerosis)*
 
Stroke or TIA*
 
Balance problems, BPPV, vertigo or dizziness*
 
Pulmonary (eg: asthma, COPD, bronchitis)*
 
Sleep apnea or CPAP use*
 
Gastrointestinal (eg: acid reflux disease, IBS)*
 
Psychiatric (eg: depression, anxiety, bipolar)*
 
Cancer*
 
Bleeding or blood clotting problems*
 
Endocrine (eg: Cushing, PCOS)*
 
Other (eg: arthritis, autoimmune disease)*
 
Do you use tobacco?*
 
Any past tobacco use?*
 
Do you drink alcohol?*
 
Any weight changes >10 lbs. this year?*
 
Do you exercise?*
 
Surgical History
Previous Head/Neck/Sinus or Ear surgeries?*
 
Tonsils Removed?*   
 
Adenoids Removed?*   
 
Please list ALL additional surgeries below:

 

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ACKNOWLEDGEMENT of RECEIPT

 
of Notice of Privacy Practices

Click here to view our Notice of Privacy Practices.

I have received the Notice of Privacy Practices from Maryland ENT Associates, effective date 9/23/2013

Patient/Legal Representative Name
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 

 

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SLEEP QUESTIONNAIRE

 
Epworth Sleepiness Scale

The Epworth sleepiness scale is used to help you Identify your own level of daytime sleepiness. Use the following scale to choose the most appropriate number for each situation: 0= Would never doze 1= Slight chance of dozing 2= Moderate chance of dozing 3= High Chance of dozing

Total score of 10 or more suggests wake-time sleepiness that may require a sleep evaluation to determine whether you are obtaining enough sleep or if you have an underlying sleep disorder. If your score is 10 or more please share this with your doctor.
Sleep Apnea Risk Questionnaire
Do you have a history of snoring?*



Have you ever been told that you have “pauses” in breathing during sleep?*



Are you overweight?*



Epworth score from above:*



Does your medical history include:







Your apnea risk score suggests:
 
5-9
Discuss complaints with your doctor
10-14
A consultation with a sleep specialist is recommended
15-19
Sleep consultation and sleep study is recommended
20+
Significant risk of sleep apnea – sleep study should be scheduled

This “Apnea Risk Score” is not intended to rule out the possibility of a sleep-related disorder. If you have concerns related to your sleep you should discuss them with your doctor.
 
Patient/Legal Representative Name

 

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WELLNESS UPDATE

 
Symptoms
Do you experience any of these symptoms?







How often do you experience these symptoms?



Do you take prescription or over-the-counter (OTC) medications for the management of your allergy symptoms?
 
Please indicate below symptoms/conditions you’ve experienced during the last 1 – 2 years








 

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PREFERRED CONTACTS

The HIPAA Privacy Rule gives individuals the right to direct how and where their healthcare provider communicates with them, such as sending correspondence to the individual’s office instead of the individual’s home. We invite you to share with us your preferred place and manner of communication. You may update or change this information at any time; please do so in writing.
I prefer to be contacted in the following manner (check all that apply):



Written Communication

Preferred Contacts
We respect your right to indicate who you prefer that we involve in your treatment or payment decisions and/or who we share your information with, including information about your general medical condition and diagnosis (such as treatment and payment options), access to medical records (PHI), prescription pick-up and scheduling appointments. Please note, however, that we may share your information as set forth in our Notice of Privacy Practices to other persons as needed for your care or treatment or the payment of services we have provided. Please update this information promptly if your preferences change.

Please indicate the person(s) you prefer we share your information with below:
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 

 

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AUTHORIZATION AND CONSENT TO TREATMENT


Assignment of Benefits and Authorization to Release Medical Information. I hereby certify that the insurance information I have provided is accurate, complete and current and that I have no other insurance coverage. I assign my right to receive payment of authorized benefits under Medicare, Medicaid, and/or any of my insurance carriers to the provider or supplier of any services furnished to me by that provider or supplier. I authorize Privia to file an appeal on my behalf for any denial of payment and/or adverse benefit determination related to services and care provided. If my health insurance plan does not pay Privia directly, I agree to forward to Privia all health insurance payments which I receive for the services rendered by Privia and its health care providers. I authorize Privia or any holder of medical information about me or the patient named below to release to my health insurance plan such information needed to determine these benefits or the benefits payable for related services. I understand that if my insurance plan does not participate in the Privia network, or if I am a self-pay patient, this assignment of benefits may not apply.

Guarantee of Payment & Pre-Certification. In consideration of the services provided by Privia and its providers, I agree that I am responsible for all charges for services provided not covered by my health insurance plan or for which I am responsible for payment under my health insurance plan. I agree to pay all charges not covered by my health insurance plan or for which I am responsible for payment under my health insurance plan. I further agree that, to the extent permitted by law, I will reimburse Privia for all costs, expenses and attorney’s fees incurred by Privia to collect those charges.

If my insurance has a pre-certification or authorization requirement, I understand that it is my responsibility to obtain authorization for services rendered according to the plan’s provisions. I understand that my failure to do so may result in reduction or denial of benefit payments and that I will be responsible for all balances due.

Consent to Treatment. As a Privia patient, I voluntarily consent to the rendering of such care and treatment as Privia providers and personnel, in their professional judgment, deem necessary for my health and well-being.

If I request or initiate a telehealth visit (a “virtual visit’), I hereby consent to participate in such telehealth visit and its recording and I understand I may terminate such visit at any time.

My consent shall cover medical examinations and diagnostic testing (including testing for sexually transmitted infections and/or HIV, if separate consent is not required by law), including, but not limited to, minor surgical procedures (including suturing), cast application/removals and vaccine administration. My consent shall also cover the carrying out of the orders of my treating provider by care center staff. I acknowledge that neither my Privia provider nor any care center staff have made any guarantee or promise as to the results that may be obtained.

Consent to Call, Email & Text. I understand and agree that Privia may contact me using automated calls, emails and/or text messaging sent to my landline and/or mobile device. These communications may notify me of preventative care, test results, treatment recommendations, outstanding balances, or any other communications from Privia. I understand that I may opt-out of receiving such communications from Privia and its partners by notifying Privia at privacy@priviahealth.com, by informing my provider’s staff, or by visiting “My Profile” on my Privia Patient Portal.

HIPAA. I understand that Privia’s Privacy Notice is available at priviahealth.com/hipaa-privacy-notice/ and my care center’s website, and that I may request a paper copy at my care center’s reception desk.
 
I hereby acknowledge that I have received Privia’s Financial Policy and Privia’s Notice of Privacy Practices. I agree to the terms of Privia’s Financial Policy, the sharing of my information via HIE,* and consent to my treatment by Privia providers. This form and my assignment of benefits applies and extends to subsequent visits and appointments with Privia providers.
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
To be signed by patient’s parent or legal guardian if patient is a minor or otherwise not competent
 
*Note: If you do not want to participate in Health Information Exchange (HIE), it is your responsibility to follow the instructions outlined on the Privia HIE Opt-Out Request Form and/or contact the HIE directly.

When finished, please click the Submit Registration button below to send your form securely to our office. If you need to print a copy, please do so before clicking Submit.

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