Alpha Medical Center Form - Alpha Medical Center

Alpha Medical Center

Chiedu Austin Ogwu

Information below is for the patient being seen today

Name

Date of Birth *

Street Address

City

State

ZIP

Email Address *

Phone Number *

Social Security Number

Drivers License

Circle OneMarriedSingleDivorcedWidowed

Circle OneMaleFemale

Emergency Contact *

Emergency Contact Phone # *

How did you hear about us?InsuranceFamily/FriendInternetHospitalOther

Responsible Party - If patient is a minor, the adult with the patient today is:

Name

Phone Number

Relation to PatientMotherFatherGuardianother

Social Security Number

Address (if different from above)

City

State

Zip

Insurance Information

(Please bring insurance card to all appointments and provide to the receptionist)

Primary Subscriber name *

Date of Birth

Primary Insurance name *

Member ID# *

Group ID # *

Employer Name

Employer Phone #

Employer Address

Patient’s relationship to primary subscriberSelfSpouseChildOther

Secondary Insurance (if applicable)

Secondary subscriber name *

Member ID# *

Group ID # *

We will make a copy of your insurance card(s) for our records.

Please advise us of any changes to your personal information in the future so that we may update our records. I request that payment under my medical insurance program be made to the provider named above for services rendered to me (or my dependent child).

I also authorize the above-named provider to release to my insurance company any medical information needed for the claim.

Further, I permit a copy of the authorization to be used in place of the original.

I understand that I am financially responsible for all charges not covered by my insurance plan.

Patient or Responsible Party Signature

Date

To reduce confusion and misunderstanding between our patients and practice, we have the following financial polices. If you have any questions regarding these polices, please possible discuss them with our office manager.

Insurance/ Proof of Insurance. We participate in most insurance plans, including Medicare and Medicaid. Please contact your insurance company with any questions you may have regarding your coverage. All patients must provide their insurance card(s) at the time of check-in. If you are not insured or we are unable to verify your benefits at the time of service, payment in full is expected at each visit.

Co-payments, Co-insurances and Deductibles. All co-payments, co-insurances and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Your appointment will be rescheduled if any of these items are not available at time of service. A receipt will be provided for all payments.

Non-Covered Services. Please be aware that some - and perhaps all - of the services you receive may be non-covered by your insurance carrier. In the event that your health plan determines a service to be “not covered,” you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.

Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If you fail to provide us with the correct insurance information or notify us of changes in insurance in a timely manner, you may be responsible for the balance of a claim.

Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim.

A. I request that payment under my medical insurance program be made to Alpha Medical Center for services rendered to me or my dependent. I understand that I am financially responsible for all charges not covered by insurance.

B. Your signature on this sheet verifies your understanding of the financial policies and you agree to follow them.

Prescription Refills/Renewals. Please do not wait until your prescription runs out or has expired. Allow 72-hour notice to review your refill or renewal request. Refill and/or renewal requests will only be processed Monday through Friday you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.

during normal business hours.

Controlled drug substance (narcotic) prescriptions will not be refilled without a visit with the provider.

Appointments. We greatly appreciate you allowing us to provide you with the best care possible. Our healthcare providers and staff know your time is important. We want to be able to provide every patient with all the attention they require. Therefore, if you are not on time for your appointment and are late 15 minutes or more, it may be necessary to reschedule for another day. Please provide us with 24-hour notice if you will not be able to maintain your appointment.

I have read and understand the financial policy of the practice, and I agree to be bound by its terms. I also understand and agree that the practice may amend such terms from time to time.

Print name of patient

Date

Signature of patient of responsible of party of minor

PATIENT CONSENT FORM AND NOTICE OF PRIVACY

Use and Disclosure of Health Information for-Treatment, Payment or Healthcare Operations

I understand that as part of my Healthcare, Alpha Medical Center ("PHYSICIAN") originates and maintains health records describing my medical history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare information such as assessing quality and reviewing competence of healthcare professionals.

The PHYSICIANS Notice of Privacy Practices provides specific information and complete description of how my personal health information may be used and disclosed. I have been provided with a copy of or access to the Notice of Privacy Practices and understand that I have the right to review the notice prior to signing this consent. I understand that the PHYSICIAN reserves the right to change the Notice of Privacy Practices Prior to implementation of the revised Notice of Privacy Practices, the revised Notice will be mailed to me if I provide my address below.

I understand that I have the right to restrict the use and/or disclose of my personal health information for treatment, payment, or Healthcare operations and that the PHYSICIAN is not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that the PHYSICIAN has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing.

I request the following restrictions on the use and/ or disclosure of my personal health information.

I have been provided and have reviewed the PHYSICIAN'S Notice of Privacy Practices dated

I have reviewed this office's Notice of Privacy Practice, which explains how my medical information will be used and disclosed. Any changes to the Notice of Privacy Practices will be sent to the above stated email address provided. I understand that I am entitled to receive a copy of this document.

Print name of patient or Representative

Date

Signature of Patient or Representative

Alpha Medical Center

PATIENT HISTORY FORM

Medications -(please list any medications currently taking including the dosage and how often taking medication)

Name

Sex

Age

Date

Reason for office visit

PERSONAL HISTORY (please check all that apply)

Acid Reflux/ heart burnAids / HIVAllergiesAnemiaAsthmaAttention Deficit Disorder (ADD)Back PainBlood DiseaseBronchitisCancerChest PainCoughCirculatory ProblemsChronic Obstructive Pulmonary Disease (COPD)Congestive Heart Failure (CHF)ConstipationCrohn'sDepressionDiabetes Mellinis TypeDiarrhea,

Difficulty UrinationEar ProblemFeverFrequent UrinationGlaucomaGoutHand PainHeart ProblemsHypertensionIBS (Irritable Bowel Sydm.)Joint PainLeaking of Urine (Incontin.)Leg PainLiver DiseaseKidney DiseaseKnee PainMigraine HeadacheNervous ProblemsNumbness or Tingling in the Diabetes Mellinis Type legs/HandsObesity

PacemakerPsychiatric CareRheumatic FeverSeizureSexual Transmitted DiseaseShortness of BreathSickle Cell AnemiaSinusitisSore ThroatStrokeSwelling of feet or handsSuicide ConsideredThyroid (Hyper or Hypо)TuberculosisUlcerUrinary Tract Infection (UTI)Vomiting

Last menstrual period (female only)

Other

Have you had any surgeries? (Please list what type of surgery and what year)

Medications- (Please list any medications currently taking including the dosage and how often taking medication)

Name of Medication

Dosage amount (mg)

How many per day

Are you allergic to any medications?YesNo

If yes, please list

Family History- (Please list any diseases above that your immediate family member have below)

Mother

Father

Grandparent(s)

Siblings

Do you smoke tobacco?YesNo

How many packs per week

Do you dip snuff?YesNo

Do you drink alcohol?YesNoOccasionally

How many per week?

Do you exercise?YesNo

How many times per week?

Social History-

Marital Status:MarriedSingleDivorcedWidowed

No. of Children

Not sure which procedure is right for you? We’re here to help!