Patient Registration
Patient Name
Preferred Name
Social Security No.
DOB
Gender
Male
Female
Marital Status
Married
Single
Widowed
Divorced
Partner
Address
City
State
Zip
Email
Are you disabled?
Yes
No
Cell Phone
Leave Message?
Yes
No
Home Phone
Leave Message?
Yes
No
Employer
Occupation
Pharmacy
Phone
Preferred Lab
Preferred Hospital
Primary Care Physician
Referring Physician
Upload Photo ID
To select multiple files, hold down the CTRL or SHIFT key while selecting.
If other family members are seen in this office, please list:
Emergency Contacts / Release of Medical, Billing and Appointment Information
I authorize Nephrology Associates M.D., PA to discuss my medical, billing and appointment information with the following individuals:
Spouse Name
Phone
DO NOT
discuss billing
Contact Name
Phone
DO NOT
discuss billing
Relationship to Patient
Add another?
Contact Name
Phone
DO NOT
discuss billing
Relationship to Patient
Financial Policies
Insurance / Medical
Records Authorization
By signing and/or receiving medical services from Nephrology Associates, you agree to the following:
I request payment of authorized Medicare, Medigap, or other insurance benefits to Nephrology Associates, M.D., P.A. for any services provided to me by those physicians and or nurse practitioners; I understand that I will be responsible for any coinsurance, deductible amounts, and any non-covered services.
I hereby authorize Nephrology Associates, M.D., P.A. to release medical or other necessary information required by my private insurance carrier, Medicare, Medigap and its agents to determine benefits for services provided.
This authorization will also permit Nephrology Associates, M.D., P.A. to provide requested information or excerpts from the patients record to any physician, hospital, laboratory, radiological facility, or other health care provider from which the patient has been referred or being referred to support continuity of care.
I understand that I am required to give a 24-hour notice if I wish to cancel my appointment so that my time can be given to another patient. Nephrology Associates, M.D., P.A. reserves the right to charge a $50.00 “no show” fee if I fail to provide this notice.
Additionally, I understand that I have a contract with my insurance company that governs co-payments for office visits. Co-payments must be paid prior to being seen by the physician/nurse practitioner. If co-payment is not received, I may be required to re-schedule my appointment.
This authorization shall remain in effect until revoked by me in writing. A photocopy of this authorization is considered as valid as the original. I certify that I have read and understand the “Financial Policies” and agree to all terms and conditions stated above.
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, and that I understand and agree to the above statements.
Date
Patient Name
Insurance Information
Do you have healthcare insurance?
Yes
No
Primary Insurance Name
Please upload a copy of your Primary insurance card
*
To select multiple files, hold down the CTRL or SHIFT key while selecting.
Subscriber Name
Relationship to Patient
ID Number
*
Group Number
*
Do you have secondary healthcare insurance?
Yes
No
Secondary Insurance Name
Please upload a copy of your Secondary insurance card
*
To select multiple files, hold down the CTRL or SHIFT key while selecting.
Subscriber Name
Relationship to Patient
ID Number
*
Group Number
*
“Self-Pay” Patient Payment Policy and Good Faith Estimate
Definition
: “Self-Pay” is any individual that either does not have any insurance coverage or has insurance coverage where our Physicians or Nurse Practitioner are considered as
NON-PARTICIPATING
or chooses not to utilize their benefits.
Below you will find the different Office Visit charge amount ranges for nephrology-related services and their cost to you. The exact level of Office Visit cannot be determined until after you have been seen by your Physician or Nurse Practitioner and they complete your chart visit documentation. The estimated costs are valid for 12 months from the date of this Good Faith Estimate (GFE).
New Patient:
Office visit, service codes 99202, 99203, 99204 or 99205 (patients not seen by any Nephrology Associates provider within the last 3 years). New Self-Pay patients will be required to make an initial payment of $135 at time of service. A statement with any remaining balance from this office visit will be mailed to you. Once received, payment in full will be expected.
New Patient
Charge range: $135 - $310
Established Patient:
Office visit, service codes 99212, 99213, 99214 or 99215 (patients seen by a Nephrology Associates provider in the last 3 years). Established Self-Pay patients will be required to make an initial payment of $75 at time of service. A statement with any remaining balance from this office visit will be mailed to you. Once received, payment in full will be expected.
Established Patient
Charge range: $75 - $215
Appointment Date
Appointment Provider Name
I agree to the Self-Pay Policy as stated above.
Patient Name
DOB
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, and that I understand and agree to the above statements.
Date
Disclaimer
Effective January 1, 2022, a ruling went into effect called the "No Surprises Act" which requires practitioners to provide a "Good Faith Estimate" for self-pay care. This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
If you are billed $400 or more than your Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to
www.cms.gov/nosurprises/consumers
or call
1-800-985-3059
.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
Do you have Medicare?
Yes
No
Patient Name
DOB
Today's date
Is the patient a Veteran?
Yes
No
Did the VA refer you here for treatment?
Yes
No
Does the patient have a VA “fee basis ID card”?
Yes
No
Do you have a Federal Black Lung card?
Yes
No
Is this medical condition due to an accident of any kind?
Yes
No
Please explain
Is the patient covered by an employer’s health insurance plan through their own employment or that of a family member that is not retiree coverage?
Yes
No
Notice of Privacy Practices
Click here
to view and print our Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I have received Nephrology Associates, M.D., P.A. Notice of Privacy Practices, and a personal copy was made available for me.
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, and that I understand and agree to the above statements.
Date
Patient Name
Medical History
Patient Name
DOB
Age
Today's date
Referred By
Insurance
Briefly state current problem
Severe or Prolonged Illness?
Yes
No
Please describe
Medications You Are Presently Taking
(including laxatives and vitamins)
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
Add another?
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
Add another?
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
Add another?
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
Add another?
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
Add another?
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
Add another?
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
Add another?
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
Add another?
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
Add another?
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
Add another?
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
Add another?
Select Method
Oral Capsule
Oral Tablet
Lozenge
Gargle
Drops
Nasal Spray
Dry Powder Inhaler
Injection
Pen Injecter
Not Listed
How many days per week do you take NSAIDS?
Ex. Ibuprofen, Aspirin, Naproxen, Celebrex, Meloxicam...
List Any Allergies to Medications
(or other allergies you have)
Add another allergy?
Add another allergy?
Add another allergy?
Add another allergy?
Add another allergy?
Problems a Physician Has Treated You For
Yes
No
High Blood Pressure (HTN)
Yes
No
Diabetes
Yes
No
Stroke
Yes
No
Heart Stents
Yes
No
Bypass Surgery
Yes
No
Heart Failure
Yes
No
High Cholesterol
Yes
No
Acid Reflux
Yes
No
Neuropathy
Yes
No
Acute Kidney Injury
Previous need for Dialysis?
Yes
No
Yes
No
Premature Birth
Yes
No
Other
Yes
No
Have you had a blood transfusion?
List of All Surgeries
Add another?
Add another?
Add another?
Add another?
Add another?
List of All Hospitalizations
Add another?
Add another?
Add another?
Add another?
Add another?
Family History
Native American Heritage?
Yes
No
African American Heritage?
Yes
No
Father Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Mother Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Brother Living?
Yes
No
N/A
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another brother?
Second Brother Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another brother?
Third Brother Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another brother?
Fourth Brother Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Sister Living?
Yes
No
N/A
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another sister?
Second Sister Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another sister?
Third Sister Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another sister?
Fourth Sister Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Son Living?
Yes
No
N/A
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another son?
Second Son Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another son?
Third Son Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another son?
Fourth Son Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Daughter Living?
Yes
No
N/A
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another daughter?
Second Daughter Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another daughter?
Third Daughter Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Add another daughter?
Fourth Daughter Living?
Yes
No
Age
History of Kidney Disease
Yes
No
Present Diseases
Age at Death
Cause of Death
Do any other
blood
relatives have the following problems?
Yes
No
Heart Disease:
Father
Mother
Brother
Sister
Son
Daughter
Yes
No
Cancer:
Father
Mother
Brother
Sister
Son
Daughter
Yes
No
High Blood Pressure:
Father
Mother
Brother
Sister
Son
Daughter
Yes
No
Tuberculosis:
Father
Mother
Brother
Sister
Son
Daughter
Yes
No
Kidney disease:
Father
Mother
Brother
Sister
Son
Daughter
Yes
No
Diabetes:
Father
Mother
Brother
Sister
Son
Daughter
Yes
No
Thyroid Disease:
Father
Mother
Brother
Sister
Son
Daughter
Yes
No
Asthma:
Father
Mother
Brother
Sister
Son
Daughter
Yes
No
Blood Disease:
Father
Mother
Brother
Sister
Son
Daughter
Social History
Cups of coffee/day
Cups of soda/day
Cups of tea/day
Cups of other sweetened drinks/day
Amount of alcoholic beverages/day
Recreational drugs used, past or present
Have you ever smoked regularly?
Yes
No
Packs of cigarettes/day
How many years?
If quit, when
Current Weight
Height
Calculate your BMI
BMI
Weight five years ago
Exercise program
Diet
Review of Systems
Yes
No
Headaches
Yes
No
Decreased vision
Yes
No
Decreased hearing
Yes
No
Nose bleeding
Yes
No
Sinus trouble
Yes
No
Trouble swallowing
Yes
No
Dry cough
Yes
No
Productive cough
Yes
No
Coughing up blood
Yes
No
Shortness of breath on exercise
Yes
No
Lung disease
Yes
No
Shortness of breath lying down
Yes
No
Shortness of breath waking you up
Yes
No
Chest pain on exercise
Yes
No
Ankle swelling
Yes
No
Heart murmurs
Yes
No
Pain in legs with exercise
Yes
No
Infections in kidneys or bladder
Yes
No
Blood in urine
Yes
No
Kidney stones
Yes
No
UTIs
Yes
No
Burning on urination
Yes
No
Trouble starting urine
Yes
No
Trouble holding urine
Yes
No
Need to urinate at night
Yes
No
Kidney x-ray
Yes
No
Prostate enlargement
Yes
No
Erectile dysfunction
Yes
No
Constipation
Yes
No
Diarrhea
Yes
No
Nausea
Yes
No
Vomiting
Yes
No
Vomiting blood
Yes
No
Rectal bleeding
Yes
No
Ulcers
Yes
No
Back pain
Yes
No
Arthritis
Yes
No
Gout
Yes
No
Dizziness
Yes
No
Nervousness
Yes
No
Trouble with balance
Yes
No
Neuropathy*
*(numbness or uncomfortable sensation in feet/hands)
Women Only
Yes
No
Pre-Eclampsia
Yes
No
Pregnancy with high blood pressure (HTN)
Diabetic Form
Do you have diabetes?
Yes
No
How many years have you had diabetes?
How was your diabetes discovered?
Have you ever been on Insulin?
Yes
No
Are you currently using Insulin?
Yes
No
How many years?
How many units?
Has your diabetes ever been treated with a pill (oral therapy)?
Yes
No
How many years?
Have you ever been to an ophthalmologist (eye doctor)?
Yes
No
What did they tell you?
Have you ever had bleeding in your eyes?
Yes
No
Have you ever had laser treatments to your eyes?
Yes
No
Which one?
Right
Left
Both
How is your eyesight?
Are you able to read the newspaper?
Yes
No
Has anyone ever told you that your kidney function is below normal?
Yes
No
What did they tell you?
When did it start?
Has anyone ever told you that you have protein or albumin in your urine?
Yes
No
Has anyone ever told you that you have blood in your urine?
Yes
No
How do you monitor your blood sugar at home?
Accuchecks?
Yes
No
Urine test?
Yes
No
Are you familiar with the term “glycohemoglobin” or “hemoglobin A1C”?
Yes
No
What does it mean?
Have you had any heart problems?
Yes
No
What kind?
Have you had swelling in your legs?
Yes
No
When did it start?
Do you have high blood pressure?
Yes
No
When did it start?
How do you monitor it at home?
What are your typical readings?
/
Have you had numbness, tingling, nerve pain or nerve problems in your legs or hands?
Yes
No
Please decribe the problem
Office Policy
Please read the following information carefully
Our office will do whatever we can to assist you. If you have any questions or problems, please do not hesitate to contact our office.
All patients must complete the patient information form and sign this policy agreement in order to be seen in this office.
Dear Patients and Families,
We thank you for choosing Nephrology Associate M.D., P.A., and look forward to working with you. We strive to provide the very best care and in order to do so we would like to take this opportunity to acquaint you with our office policies. Please take a few moments to read over the following information.
In addition, we suggest you review your health insurance policy and familiarize yourself with the coverage and limitations that it provides.
APPOINTMENTS
We ask that you try to schedule your follow-up appointments as soon as possible - hopefully after each office visit - as routine follow-up time slots are typically booked for several weeks into the future at any given point in time. If you are unable to keep your appointment, please notify our office two working days
(48 hours)
in advance, so the appointment time can be given to another patient who needs to be seen. Nephrology Associates, M.D., P.A. reserves the right to charge a $50 “No Show” fee if you fail to provide this notice.
As insurance does not pay for missed appointments, the patient/guarantor is responsible. Please note that two consecutive missed appointments may result in being discharged from care.
We will try to contact you to confirm each appointment five to ten working days ahead of time. This text/email is a
courtesy
, and our failure to reach you will not relieve you of your responsibility for any missed appointment charges.
Please make sure our office has the most up-to-date phone number and/or email address, so you receive these notifications. If you are running late for your appointment, please call our office immediately to let our staff know.
CONTINUITY OF CARE
Please provide us with a list of physicians that should receive copies of your chart notes, labs, and other medical records. We want to make your healthcare journey as smooth as possible and keep everyone on the same page.
PRESCRIPTIONS
If you are on medication, please request any needed renewal prescriptions at the time of your appointment. In general, you will be provided with enough refills to last until your next expected appointment. If you do require refills between appointments,
please contact us during regular phone hours 8:30 AM to 4PM Monday through Thursday and 8:30AM to 11:30AM on Friday.
Please notify our office of the need for a prescription three business days in advance, as we do not provide “emergency fills.”
Please bring a list of all of your current prescriptions and over-the-counter medications you take to each appointment.
LABS
When you have your follow-up appointment, you must complete labs 2 weeks prior, and some patients may have regular interval labs scheduled. Three of our offices have partnered with Quest labs and provide the ability to get your labs completed at the same place you have your appointment. The offices are: Olathe, Shawnee/Georgetown, and NKC. Please call our office for lab hours of operation.
You may also go to any lab of your choosing. If you go to an outside lab, please tell us what lab you have gone to so we can track the results and provide them at your appointment. We will also fax the lab order to any lab of your choosing. Before you go or while you are at the lab, please alert our office, and we will fax the lab order right over, if you do not have a copy of it.
Our nurses give you a call 2 weeks before your appointment to remind you to do your labs. This is a courtesy they provide. If they leave a message, please call back and let us know where the labs were done.
For 24-hour urine collection, please make sure to turn these in at least 2 weeks before your appointment as some of these tests take longer to process.
LETTERS AND FORM COMPLETION
We require a minimum of 48 hours for all letters and form completion. Any information that you would like forwarded to another provider, school, attorney, employer, etc. requires a signed release of information. In some cases, we may require you to schedule an appointment for the completion of these forms. Please contact our office to inquire whether a scheduled appointment will be necessary.
There may be a fee associated
.
I have read and agree to adhere to the office policies above.
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, and that I understand and agree to the above statements.
Date
Patient Name