Central Maryland Nephrology

CENTRAL MARYLAND NEPHROLOGY

Welcome to our practice
Patient name *
Birthdate *
Gender *

Male Female
Race/ethnicity
What is the purpose of your visit?
Describe your medical and surgical history
List your medications & doses
Medications (continued)
What is (was) your occupation
Medication allergies (or write "none")
How often do you drink alcohol
Describe your tobacco history
Describe the medical history of your parents, siblings, children, and other relatives with kidney problems
Click the box if you have any of the following:

Weight loss >10lbs Weight gain >10lbs Fatigue Rashes Fevers Sinus problems Diminished or blurry vision Hearing loss Swollen lymph nodes Chest pain Short of breath at rest Short of breath with exertion Palpatations Chronic cough Abdominal pain Constipation Diarrhea Blood in stool Heartburn/reflux Nausea Foamy urine Blood in urine Painful urination Frequent urination Urination at night Urinary tract infections Leg swelling Weakness of arms or legs Numbness in feet Joint pains/joint swelling Sores on feet or toes Dizziness/vertigo Tremors Headaches Blackouts Depression Anxiety Memory loss
Name of primary care & other providers you have seen (phone numbers & addresses if possible) *
On a scale of 1-10 (10 being best), how do you rate your overall health?
MEDICAL INSURANCE
Patient name and address *
Birthdate *
Home phone
Email
Cell phone
Social security number
Gender

Male Female
Marital status

Married Single
Emergency contact name & phone #
Employer name, address, and phone number
Name & address of policy holder (if different from patient)
Insurance company name and address *
Policy ID number *
Policy group number *
Is the patient covered by additional/secondary insurance?

Yes No
Name & address of secondary policy holder (if different from patient)
Secondary insurance company name and address
Secondary policy ID number
Secondary policy group number
Secondary insurance employer name, address, phone number:
OFFICE POLICIES
Discussions with Family and Friends

Family members and friends may inquire about your treatment. We will use our discretion when discussing your care with others unless you provide us with specific instructions. Please list any individuals with whom you either authorize or prohibit us from discussing your care.
List people with whom we may share your health information
List people with whom we may NOT share your health information
May we leave voicemails with medical information? If yes, list phone numbers
Missed Appointment Policy

If you cancel your appointment, Central Maryland Nephrology requires a minimum of 24 hours advance notice. You may cancel by phone or in writing. You also may leave a message or voicemail with our answering service if the office is closed when you call.

There will be a $50 charge if you cancel with less than 24 hours notice unless there is an emergency that strictly prohibits your ability to keep the appointment. You will be required to pay the $50 charge before being allowed to reschedule your appointment.
Use and Disclosure Of Your Medical Information

This document authorizes Central Maryland Nephrology to share your medical information with employees and contractors of our practice, and with other healthcare providers who are contributing to your care or are consulted. You also allow us to share relevant information with your insurer or other third-party payor that is responsible for paying all or part of the cost of your care. You also authorize us to use and disclose information necessary for our operations such as quality assessments and appointment reminders. You also may be asked to authorize us to make additional disclosures not covered elsewhere in this Notice. In such cases, we will provide you with the information to be disclosed, the entity to whom it will be disclosed, and the pupose of the disclosure prior to disclosure.

You may revoke any of the above authorizations by providing us with a written notice. You also may request an accounting of your disclosures except for disclosures made for treatment, payment, and healthcare operations.

We may be required by law to disclose your records without your approval in certain circumstances. Examples include subpoenas for records or if public responsibility requires a disclosure to protect public health.

You have the right to inspect and copy your health information. If you feel the information we have is inaccurate, you may request, in writing, an amendment to your medical records. If we do not agree to your request, you may ask that your statement be placed in your medical record.

You also have the right to obtain a paper copy of this notice.

Central Maryland Nephrology is required by law to maintain the privacy of your protected health information. If you believe your rights have been violated, you may contact the U.S. Department of Health and Human Services. You also may contact us in person, by phone, or in writing. We will not retaliate against a patient for making a complaint.

Central Maryland Nephrology reserves the right to change its privacy practices and to make new policies for all protected health information that it maintains.

We will distribute an updated Notice to Patients if necessary.
Medication Prescriptions

Our goal is to respond to prescription requests within 2 business days. We prefer to interact with pharmacies via our electronic medical record, but we will use call or fax when needed. We ask that our patients do the following:

1. If you are out of refills, tell your pharmacy to send us a refill request via our electronic medical record. We ask that you request refills from your pharmacy at least 1 week before your supply runs out. If you use a mail order pharmacy, request refills several weeks in advance. If we do not authorize your refill within 2 business days, contact us directly or through your patient portal.

2. You must be seen in our office at least once per year to receive additional refills. Our physicians and staff may deny refills if you have not been seen in over a year.

We may use health information exchange systems to electronically transmit, receive, and/or access your medication prescription history.
I authorize release of my healthcare information for the purpose of administering claims for insurance benefits. I also authorize payment of insurance benefits otherwise payable to me directly to Central Maryland Nephrology. I also approve Central Maryland Nephrology's office policies as documented above.
Signature of person filling out form

Clear
If signing on behalf of patient, list name & relationship
Date

Month Day Year
Date
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CENTRAL MARYLAND NEPHROLOGY

MEDICAL INSURANCE

OFFICE POLICIES