Pittsburgh New Patient Paperwork

New Patient Information

It may take about 8-10 minutes to complete the following form.
Today's Date *

Month Day Year
Date
Patient Full Name *
Email *
example@example.com
Address *

Address

Street Address Line 2

City
State Abbreviation *
Zip Code *
Home Phone *
Cell Phone *
Work Phone *
Social Security Number *
Date of Birth *

Month Day Year
Date
Age *
Sex *

Male Female
How did you hear about us? *

Internet Advertisement Friend/Family PCP Referral Specialist/Doctor other than PCP
If you chose PCP Referral above, what was the physician's name?
If you chose Specialist/Doctor above, what was the physician's name?

Patient's Responsible Party

If different from above.
You can skip this section if it does not apply.
Responsible Party's Name
Responsible Party's Address

ADDRESS

Street Address Line 2

CITY
State Abbreviation
Zip Code
Home Phone
Cell Phone
Work Phone
Social Security Number
Date of Birth

Month Day Year
Date
Age
Sex

Male Female

Primary Insurance Information

Please present insurance card at time of check in.
Primary Insurance Name *
Name of Insured on Primary Insurance *
Primary Insurance Card Holder's Relationship to Patient *
Insured's ID # on Primary Insurance *
Group # on Primary Insurance *

Secondary Insurance Information

Skip this section if you do not have secondary insurance.
You can skip this section if it does not apply.
Secondary Insurance Name
Name of Insured on Secondary Insurance
Secondary Insurance Card Holder's Relationship to Patient
Insured's ID # on Secondary Insurance
Group # on Secondary Insurance

Pharmacy Information
Pharmacy of Choice
City
Pharmacy Phone Number
Please enter a valid phone number.
Pharmacy Fax Number
Please enter a valid phone number.

Physician Information
Primary Care Physician *
Primary Care Physician's Phone Number *

Medicare Patient Information
You can skip this section if it does not apply.
MEDICARE PATIENTS: I request that payment for authorized Medicare benefits be made either to me or on my behalf to Laurel ENT & Allergy, PC for any services furnished me by physician or supplier. I authorize any holder of medical information about me to release to the CMS and its agents any information needed to determine these benefits or the benefits payable for related services.
Medicare Patient Name
I authorize the release of medical information to my PCP or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications & prescriptions. I also authorize payment of medical benefits to the physician.
In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding or payment policies, our staff is trained to consistently inform you of the financial payment policies of the office. Payment is required for all services at the time they are rendered unless you are in a prepaid plan in which we participate. Applicable copayments and deductibles will be collected. We accept payment in form of cash, check or credit card. In the event of hospitalization or major procedures, our office may file with the appropriate Insurance. However, before such claims are filed, coverage will be pre-verified and you will be asked to pay any unmet deductible, non-covered services and copayments. If payment is not made to our office in full within 30 days you may incur a late fee. If further collection is required you could incur collection fees, attorney fees, and all court costs to collect upon any debt you have owing our office.
Medicare Patient or Responsible Party
Medicare Patient or Responsible Party's Signature

Clear

Family Disease History

Please list any BLOOD RELATIONS who have had the below diseases:
Cancer, what type? *
Thyroid Disease? *
Allergies? *
Sinus Problems? *
Asthma? *

Authorization to Release Information
This office adheres to strict policies with regard to release of confidential information. If you authorize Laurel ENT and Allergy, PC staff to release information regarding your care to family members, please list up to three contacts with their full names, phone number and their relationship to you.
NAME *
PHONE *
RELATIONSHIP
NAME
PHONE
RELATIONSHIP
NAME
PHONE
RELATIONSHIP

EMERGENCY CONTACT
Please give the name and number of up to two relatives or friends whom we may contact in the event of a medical emergency.
Emergency Contact Name *
Emergency Contact Phone *
Please enter a valid phone number.
Relationship *
Emergency Contact Name
Emergency Contact Phone
Relationship

Telephone Messages
We may need to contact patients regarding appointments, scheduling tests, test results, etc. It may be necessary for us to contact you. It is our policy to leave detailed messages at your home if you are not available or we may need to contact you at work if an emergency arises.
May we contact and/or leave a message at home? *

Yes No
May we contact and/or leave a message at work? *

Yes No
Signature *

Clear

Statement of Patient Financial Responsibility
Laurel ENT and Allergy, PC appreciates the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. This responsibility obligates you to ensure payment of our fees in full. As a courtesy, we will verify coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill.

You are responsible for your payment of any deductible and copayment/co-insurance as determined by your contract with your insurance carrier. We expect these payments at time of service. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by your insurer. If your insurance carrier denies any part of your claim, or if you or your physician elects to continue past your approved period you will be responsible for your balance in full.

By signing below, I state that I have read and agree to the above policy regarding my financial responsibility to Laurel ENT and Allergy, PC, for providing services to me or the above named patient. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to Laurel ENT and Allergy, PC, the full and entire amount of bill incurred by me or the above named patient; if applicable any amount due after payment has been made by my insurance carrier is my responsibility.
Patient/ Guarantor Signature *

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Consent for Treatment and Authorization to Release Information

I hereby authorize Laurel ENT and Allergy, PC, through its appropriate personnel, to perform or have performed upon me, or the above named patient, appropriate assessment and treatment procedures.

I further authorize Laurel ENT and Allergy, PC, to release to appropriate agencies, any information acquired in the course of my or the above named patient's examination and treatment.
Patient/Guarantor Signature *

Clear
Cancellation/No Show Policy

We understand there may be times when you miss an appointment due to emergencies or obligations to work of family. However, we urge you to call 24 hours prior to canceling your appointment.

I understand that if I no show for 3 consecutive appointments, or cancel for a total of 3 appointments, I may be discharged from care.

The practice will notify you in writing, via certified mail if you are discharged from care.

I have read and understand the above information, and I agree to the terms described:
Patient/Guarantor Signature *

Clear
Failure to Pay

If you fail to remit payment after 90 days you will automatically be sent to collections, any additional fees may be applied and will be your responsibility. It is your responsibility to remit in full, and in the entire amount owed to the collection agency.
Patient/Guarantor Signature *

Clear

INFORMED CONSENT FOR TELEMEDICINE SERVICES
Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, follow-up and/or education, and may include any of the following: patient medical records, medical images, live two-way audio and video, output data from medical devices and sound and video files. Electronic systems will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption. | understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in the use of telemedicine that identifies me will be disclosed without my consent.

I understand that | have the right to withhold or withdraw my consent to the use of telemedicine during my care at any time, without affecting my right to future care or treatment. | understand that | may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated and all of my questions have been answered to my satisfaction.

I hereby authorize Pittsburgh Sinus Centers to use telemedicine during my diagnosis and treatment.

Signature of Patient (or person authorized to sign for patient):
Signature *

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If authorized signer, relationship to patient *
Should be Empty:

New Patient Information

Patient's Responsible Party

Primary Insurance Information

Secondary Insurance Information

Pharmacy Information

Physician Information

Medicare Patient Information

Patient History

Family Disease History

Authorization to Release Information

EMERGENCY CONTACT

Telephone Messages

Statement of Patient Financial Responsibility

INFORMED CONSENT FOR TELEMEDICINE SERVICES