Patient Health History

In order for us to obtain a complete medical history, it is important for you to fill out this form as completely as possible. This is very important information. Please fill out every item. It is important for your doctor to know you have carefully reviewed every area of this form. This information will be entered into the computer and you are welcome to a copy of the report if you wish.

Patient name *  

Sex *  
Male    Female   

Primary care physician  

        

Add another medication?

Are you allergic to any medication? *  
Yes    No   

Have you ever had any problems with anesthesia (being numbed or put to sleep)? *  
Yes    No   

Have you ever been hospitalized for non-surgical reasons? *  
Yes    No   

Patient Registration

Patient name *  

Sex *  
Male    Female   

Primary care physician  

Referring physician  

Is the patient under the age of 18? *  
Yes    No   

Name *  

Is patient covered by healthcare insurance? *  
Yes    No   

The information below is being collected pursuant to the requirements of the TN Department of Health in compliance with Tennessee state law.

Race  
White  
Black  
American Indian  
Eskimo or Aleut  
Asian or Pacific islander    
Other Race  
Unknown Race  

Ethnicity  
Hispanic Origin  
Not Hispanic Origin  

Have you executed an Advance Health Care Directive, a Living Will or a Power of Attorney? *  
Yes    No   

Do you want anyone to have access to your Protected Health Information (PHI)? *  
Yes    No   

Signature of Patient or Legal Guardian – 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.

 

Patient’s Rights

The Patient's Rights Include:

• The right to receive a copy of the Notice of Privacy Practices
• The right to request confidential communications
• The right to request a restriction on the use and disclosure of Protected Health Information (PHI)
• The right to know that the covered entity is not required to agree with the requested restriction unless the request is for a restriction of information to the health plan for a service or item which the patient pays for out of pocket, with no health plan involvement
• The right to inspect and copy the PHI
• The right to request amendments and corrections to the PHI
• The right to request an accounting of PHI disclosure
• The right to be treated with respect and dignity
• The right to voice complaints or grievances about your managed care organization or the medical care provided

These are included in the Notice of Privacy Practices. Most require the patient to express their requests in writing. Providers have the authority to deny certain requests based on professional judgment.

Confidential Communications
Patients may request that the covered entity communicate with them through a method different than normally used, or to an alternate address or phone number, or through electronic means. However, the covered entity may require the patient to provide an effective means of contact, such as an address, phone number, or e-mail address, and may require the patient to explain how any additional costs to the practice will be paid. If the patient is unable to provide this information, the practice may deny the request.

Restrictions
Patients may request restrictions on how their PHI may be used. However, covered entities are not required to agree to the requested restriction. Patients may not request restrictions for uses required by law or for workers' compensation purposes. If the provider, using professional judgment, determines that agreeing to the restriction would not be in the best interest of the patient, the request may be denied.

Covered entities are required to grant a request for a restriction disclosure to the patient's health plan for a service or item for which the individual pays for totally out of pocket. This request must be made in writing. Another individual, such as a friend or family member, may pay for the service or item, but the patient cannot have another plan contribute toward the payment.

Inspect and Copy
Patients have the right to access, inspect, or copy routine PHI. However, they do not have the right to access, inspect, or copy psychotherapy notes or records restricted by another law, such as CLIA. The right to access PHI is suspended during participation in clinical trials. The patient usually agrees to this prior to the participation, and access is restored at the end of the trial.

Access may be denied to personal representatives if the provider, using professional judgment, has reason to believe that the access would not be in the patient's best interest, especially if the provider suspects that the patient may be subject to domestic violence, abuse, or neglect, or if the access may in any way endanger the patient or another individual. Access will also be denied to individuals other than the patient if the patient has requested a restriction and that request has been granted. In the case of inmates, access may be denied if it may endanger anyone there or if it might compromise the work of the facility.

A request for access must be acted upon within 30 days. If the records are not easily accessible (stored off-site, for example), the practice may have 30 more days to allow the access.

If the request is denied, this must be documented and communicated to the patient. The patient may appeal. This information must be added to the patient's medical record.

We are required to provide the information in electronic format if available. The format (examples: e-mail, disk, flash drive) must be acceptable to the requesting individual. We cannot use media provided by the patient due to security risks, and cannot require the patient to purchase media from us.

We will charge the patient the allowable rate for providing copies in any format.

Amendment
Patients may request an amendment to their medical record. The provider must review this request to determine whether the amendment is appropriate. The request may be denied:

• If the provider determines that the records are complete and accurate, the request may be denied
• If the correction does not apply to information in the designated record set
• If the information was not created by that covered entity (unless the provider who created the record is no longer available to make the correction)
• If it is part of a designated record set that is not available for access

The covered entity must act upon this request within sixty days. If it is unable to meet that response to the patient requesting the amendment, a copy of that response becomes part of the designated record set.

If the covered entity agrees to the amendment, the amendment must be made part of the designated record set and must be provided to any other agency or individual who was provided with the original information.

If the provider denies the amendment, the covered entity must communicate this information to the patient. The patient may submit a letter of disagreement and may request that the letter become part of the designated record set.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability and Accountability Act (HIPAA; "Act") of 1996, revised in 2013, requires us as your health care provider to maintain the privacy of your protected health information, to provide you with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We are required to maintain these records of your health care and to maintain confidentiality of these records.

The Act also allows us to use your information for treatment, payment, and certain health operations unless otherwise prohibited by law and without your authorization.

• Treatment: We may disclose your protected health information to you and to our staff or to other health care providers in order to get you the care you need. This includes information that may go to the pharmacy to get your prescription filled, to a diagnostic center to assist with your diagnosis, or to the hospital should you need to be admitted. If necessary to ensure that you get this care, we may also discuss the minimum necessary with friends or family members involved in your care unless you request otherwise.
   
• Payment: We may send information to you or to your health plan in order to receive payment for the service or item we delivered. We may discuss the minimum necessary with friends or family members involved in your payment unless you request otherwise.
   
• Health operations: We are allowed to use or disclose your protected health information to train new healthcare workers, to evaluate the healthcare delivered, to improve our business development, or for other internal needs.
   
• We are required to disclose information as required by law, such as public health regulations, health care oversight activities, certain lawsuits, and law enforcement.

Certain ways that your protected health information could be used or disclosed require an authorization from you: disclosure of psychotherapy notes, use or disclosure of your information for marketing, disclosures or uses that constitute a sale of protected health information, and any uses or disclosures not described in this NPP. We cannot disclose your protected health information to your employer or to your school without your authorization unless required by law. You will receive a copy of your authorization and may revoke the authorization in writing. We will honor that revocation beginning the date we receive the written signed revocation.

You have several rights concerning your protected health information. When you wish to use one of these rights, please inform our office so that we may give you the correct form for documenting your request.

• You have the right to access your records and/or to receive a copy of your records, with the exception of psychotherapy notes. Your request must be in writing, and we must verify your identity before allowing the requested access. We are required to allow the access or provide the copy within 30 days of your request. We may provide the copy to you or to your designee in an electronic format acceptable to you or as a hard copy. We may charge you our cost for making and providing the copy. If your request is denied, you may request a review of this denial by a licensed healthcare provider.
   
• You have the right to request restrictions on how your protected health information is used for treatment, payment, and health operations. For example, you may request that a certain friend or family member not have access to this information. We are not required to agree to this request, but if we agree to your request, we are obligated to fulfill the request, except in an emergency where this restriction might interfere with your care. We may terminate these restrictions if necessary to fulfill treatment and payment.
   
• We are required to grant your request for restriction if the requested restriction applies only to information that would be submitted to a health plan for payment for a health care service or item for which you have paid in full out-of-pocket, and if the restriction is not otherwise forbidden by law. For example, we are required to submit information to federal health plans and managed care organizations even if you request a restriction. We must have your restriction documented prior to initiating the service. Some exceptions may apply, so ask for a form to request the restriction and to get additional information. We are not required to inform other covered entities of this request, but we are not allowed to use or disclose information that has been restricted to business associates that may disclose the information to the health plan.
   
• You have the right to request confidential communications. For example, you may prefer that we call your cell phone number rather than your home phone. These requests must be in writing, may be revoked in writing, and must give us an effective means of communication for us to comply. If the altemate means of communication incurs additional cost, that cost will be passed on to you.
   
• Your medical records are legal documents that provide crucial information regarding your care. You have the right to request an amendment to your medical records, but you must make this request in writing and understand that we are not required to grant this request.
   
• You have the right to an accounting of disclosures. This will tell you how we have used or disclosed your protected health information. We are required to inform you of a breach that may have affected your protected health information.
   
• You have the right to receive a copy of this notice, either electronic or paper or both.
   
• You have the right to opt out of fundraising communications.

If you have any questions about our privacy practices, please contact our Privacy Officer at the number below.

You have the right to file a complaint with us or with the Office for Civil Rights. We will not discriminate or retaliate in any way for this action. To file a complaint, please contact the applicable party:

Associates in ENT, Compliance Officer
Oasis Park Bldg 1, Suite 102, 1724 Hamill Road, Hixson, TN 37343.
Phone (423) 267-6738.

Office for Civil Rights:

http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html
We are required to abide by the policies stated in this Notice of Privacy Practices, which became effective on 10/01/09.

I understand that under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my Protected Health Information (PHI). I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly
   
• Obtain payment from third-party payers
   
• Conduct normal healthcare operations such as quality assessments and physician certifications

I received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

Patient Name or Legal Guardian: *  

Signature of Patient or Legal Guardian – 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.

 

General Consent For Treatment

As the patient, you have the right to be informed about your conditions and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify appropriate treatment and/or procedure for any identified condition(s).

I request and authorize medical care as my provider, his assistant or designees (collectively called "the providers") may deem necessary or advisable. This care may include, but is not limited to, routine diagnostics, radiology and laboratory procedures, administration of routine drugs, biological and other therapeutics, and routine medical and nursing care.

I authorize my provider(s) to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I understand that my (the patient) care is directed by my provider(s) and that other personnel render care and services to me (the patient) according to the provider(s) instructions.

I understand that I have the right and the opportunity to discuss alternative plans of treatment with my provider and to ask and have answered to my satisfaction any questions or concerns.

In order to maintain an accurate and up-to-date medical record we request permission to query outside resources to obtain a list of your medications. *

In the event that a healthcare worker is exposed to my blood or bodily fluid in a way which may transmit HIV (human immunodeficiency virus), hepatitis B virus or hepatitis C, I consent to the testing of my blood and/or bodily fluids for these infections and the reporting of my test results to the healthcare worker who has been exposed. *

I HAVE READ OR HAD READ TO ME AND FULLY UNDERSTAND THIS CONSENT. I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND HAD THESE QUESTIONS ADDRESSED.

Patient name *  

Signature of Patient or Legal Guardian – 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.

 

 

Patient Financial Policy

This is an agreement between AdvancedHEALTH/dba Associates in ENT, as creditor, and the Patient/Debtor named on this form and indicated by patient/debtor signature below.

In this agreement the words "you", "your" and "yours" mean the Patient/Debtor. The word "account" means the account that has been established in your name to which charges are made and payments credited. The words "we", "us" and "our" refer to AdvancedHEALTH/dba Associates in ENT. By executing this agreement, you are agreeing to pay for all services that are rendered.

Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect. A copy of your signed financial agreement will be provided to you.

HEALTH INSURANCE - It is YOUR responsibility to:

• Ensure we have been provided with the most current insurance information relative to filing your claim including insurance card, ID number, employer, birth date and patient address. This information will be located on our patient registration form.
• Ensure we are contracted with your insurance carrier to receive maximum benefits.
• Pay your co-payment or patient portion at the time of service.
• Inform us of any insurance changes made after this signed agreement/date of service. Insurance carriers have specific timely filing guidelines and pre-authorization requirements for certain services. If revised insurance information is not provided to us within your insurances' timely filing limits, you will be required to pay for services in full. If prior authorization was required for services already received and your claim is denied for lack of authorization, you will be required to pay for services in full.
• Contact your insurance company if no correspondence is received by you within 45 days of the date of service.

• Submit a claim to your health insurance carrier based on the information provided by the patient/debtor at the time of service or as updated information is provided.
• Provide your health insurance carrier with information necessary to determine benefits. This may include medical records and/or a copy of your insurance card.
• Provide MVA patients a courtesy health insurance claim form for their records upon request.

PAYMENT OPTIONS: Per our contracted agreement with your insurance carrier, we are required to collect your co-payment on the day of service. If you do not have insurance, you are required to pay for treatment at the time of service unless other arrangements have been formally made. A separate self-pay financial agreement will be provided to you. Our office collects all copays plus estimated coinsurance and deductibles at the time of service. A twenty-five dollar ($25.00) returned check fee will be assessed to the patient account per incident. For convenience, payments may be made online. To utilize this service you will need your unique statement code. This information can be found on the patient statement you will receive reflecting your balance. Patients who no-show may be subject to a no-show fee.

PENDING APPROVALS FOR SERVICES: In the event we are unable to obtain approval for services and you wish to proceed, we will not bill your insurance. Services will be reduced to the in-network insurance allowable amount and will apply to the patient's responsibility.

Written approval/authorization by your employer and/or workers' compensation carrier prior to your initial visit is needed. We will contact your case manager and/or supervisor to confirm your workers' compensation injury. If this claim is denied for any reason by your employer or your employer's workers' compensation carrier, you will be responsible for payment in full. If denial is made by workers' compensation, health insurance can be filed for these denied services and you will be held responsible for the account.

Yes, I was involved in a MVA on Unless prior agreement has been reached or I am a Medicare recipient, my health insurance will be filed for services related to this accident. In the event I do not provide insurance information upon initial visit, I understand insurance denials may occur depending on type of service(s) received or carrier specific filing requirements. I agree, as the patient or patient's guardian, I am ultimately responsible for all balance(s) due to this facility and/or its physician(s) for services rendered regardless of insurance denial(s) or unfavorable case outcomes. If I have chosen an attorney to oversee my case, this financial agreement will serve as a Letter of Protection to my attorney. I further understand my account may be handled by an outside entity that specializes in attorney lien accounts at the facility’s discretion.

Signature of Patient or Legal Guardian – 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.

 

Billing Information

STATEMENTS: A statement of account will be provided to you if insurance has paid leaving a patient portion, denied or no response is received. Due to the type of service we provide, you may receive billing from more than one practice, otherwise known as split billing. The balance on your statement is due and payable within 30 days of receipt unless other arrangements are made with our billing department. The statement will be sent to the address provided at the time of service. In the event your mailing address changes after your service date and your account has not been paid in full, you are required to notify our billing office of this change by email at Billing@OurAdvancedHEALTH.com or call 615-239-2018. In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child at time of service will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, court documentation is required for any guarantor address changes, otherwise, it is the authorizing/custodial parent's responsibility to collect from the other parent. Any account with a credit balance of less than $5.00 will not be refunded without a specific request from the patient/debtor.

DELINQUENT ACCOUNTS: We review past due accounts frequently and at every statement cycle. Your communication and involvement to ensure your balance is paid timely is important to us. It is imperative that you maintain communications and fulfill your financial agreement and arrangements to keep your account active and in good standing. If your account becomes sixty (60) days past due, further steps to collect this debt may be taken. If you fail to pay on time and we refer your account(s) to a third party for collection, a collection fee will be assessed and will be due at the time of the referral to the third party. In addition, we reserve the right to deny future non-emergency treatment for any and all debtor-related unpaid account balances.

CONSENT TO CONTACT: I grant permission and consent to AdvancedHEALTH/dba Associates in ENT and its agents, assignees, and contractors (which may include third party debt collectors for past due obligations): (1) to contact me by phone at any number associated with me, if provided by me or another person on my behalf; (2) to leave messages for me and include in any such messages amounts owed by me; (3) to send me text message or emails using any email address I provided or any phone number associated with me, if provided by me or another person on my behalf; and (4) to use prerecorded/artificial voice messages and/or an automated telephone dialing system (an auto dialer) as defined by the Telephone Consumer Protection Act in connection with any communications made to me as provided herein or any related scheduled services and my account. I understand that my refusal to provide the consent described in this paragraph will not affect, directly or indirectly, my right to receive healthcare services.

WAIVER OF CONFIDENTIALITY: You understand if your account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

MEDICAL RECORDS: You will be required to request in writing or sign a medical authorization form for the release of your medical records to any organization or physician. Please note that you will be charged a $20 flat rate for 1-5 pages plus .50 per additional page and postage to cover the cost of the production of your medical records.

• If age 18 years and over, you should contain documentation of whether a medical advance directive has been executed for Medicaid/Medicare members. A copy should be on file within the office
   
• Please notify the office if you have a Living Will or Power of Attorney

Signature of Patient/Debtor – 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.

 

Release Of Medical Information

Patient name *  

By signing below, I authorize Associates in Ear, Nose and Throat to release my medical and billing information to:

Yes    No    Spouse  

Yes    No    Children  

Yes    No    In-Laws  

Yes    No    Caregivers  

Yes    No    Parents  

Yes    No    Others  

Associates in Ear, Nose and Throat may leave appointment information on my voicemail:

Yes    No   Home  

Yes    No   Work  

Yes    No   Relative  

I authorize the following to pick up prescriptions, X-rays, etc.

Yes    No    Spouse  

Yes    No    Relative  

Yes    No    Caregiver  

Please note that you will be charged a $20 flat rate for 1-5 pages plus .50 per additional page and postage to cover the cost of the production of your medical records. I understand that Associates in Ear, Nose and Throat will ask for the identification of the person picking up the patient medical information or products.

Signature of Patient or Legal Guardian – 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.