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 Leg swelling Weakness of arms or legs Numbness in feet Joint pains/joint swelling Sores on feet or toes Dizziness/vertigo Tremors Headaches Blackouts Anxiety or depression Memory loss
Have you had any labs drawn outside of Quest or LabCorp? If so, please provide the lab name/phone number/address and the dates of the labs if possible
Have you had any radiology studies (ultrasound, CT scan, etc.) done? If so, please provide radiology company name/phone number/address and the dates of the scan(s) if possible.
Name of primary care & other providers you have seen (phone numbers & addresses if possible)
Preferred pharmacy (provide phone & fax numbers and address 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.
Our Billing Policy

Central Maryland Nephrology has always been committed to putting our patients first to provide the best possible outcome for their care. We are pleased to offer payment plans, discounted rates for self-pay patients when appropriate, and assistance with understanding your insurance policy at it relates to our office.

Our billing team will exhaust all reasonable options for ensuring that patient insurance is billed first and processed correctly before transferring over a balance to a patient. Failure to provide appropriate insurance information in a timely manner may result in a denial by the insurance payer, at which time the cost would be transferred to the patient.

In order to help us, please do the following:
-Communicate any changes in your insurance as soon as you are aware of them.
-Provide us with any supplemental insurance information you may have.
-Submit new patient forms with insurance information prior to your appointment.
-Respond to statements and/or inquires from our billing office.

Please also be aware that all billable medical services are processed according to your individual insurance policy (if applicable). We do not determine cost-shares or a patient's financial obligation. Please refer to your insurance policy for additional guidance.
Our Telehealth Policy

Telehealth allows for health-related services and information via electronic information and telecommunication technologies. While we are excited to utilize telehealth for our patients when appropriate, we also must follow national and payer standards when it comes to providing this service.

Telehealth is a billable service as our providers provide contact, care, advice, reminders, education, intervention, and monitoring. Patients with insurance are responsible for any cost share (i.e. copay, coinsurance) associated with a telehealth interaction. Self-pay patients are responsible for the self-pay rate associated with the same visit.

We utilize a HIPAA compliant platform for our virtual appointments. We follow all guidelines relating to telehealth and the protection of your information. By choosing to log in and utilize our platform, you are considered to have given consent to the aforementioned modality and all the risks contained therein. If you do not wish to have a telehealth appointment, contact the office and we will schedule an in-person appointment for you.

Please be aware that providers may still determine that it is medically necessary for a patient to be seen in person rather than, or in addition to, a telehealth visit.
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.

I understand that cost-shares associated with services provided are determined by my individual insurance policy. I understand that failure to provide appropriate insurance information in a timely manner, may result in a denial by my insurance payer at which time the cost would be transferred to me. I agree to pay any costs associated with my care as determined by my individual policy or by the self-pay rate communicated to me.
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CENTRAL MARYLAND NEPHROLOGY

MEDICAL INSURANCE

OFFICE POLICIES