New Patient Packet - Pulmonary and Critical Care Associates & Sleep Diagnostic Center

Dear Patient,
Your new patient appointment is on at arrival time for appointment.
The following is our new patient paperwork. Please fill out the forms completely and bring it to your appointment along with the following items:
- Insurance Card(s) and Photo ID (FOR ALL INSURANCES: IT IS THE RESPONSIBILITY OF THE PATIENT TO CONTACT THEIR INSURANCE TO DETERMINE IF THE DOCTOR YOU ARE SEEING IS IN OR OUT OF NETWORK)
- If your insurance is an HMO, please bring the corresponding referral. NOTE: If you do require a referral, please call the office the business day prior to your appointment to make sure we have received it.
- List of all your medications and dosages as well as any medication allergies and reactions (see attached sheet).
- If you had any recent chest x-rays or chest CAT Scans, please bring the disc or actual film, not just the report.
- If you are being referred, please bring any useful information from your doctor to your appointment or have them fax it to our office. Ex. Office visit notes, labs, radiology, etc
If you have any questions about your new patient appointment, need to cancel, or reschedule please call 703-722-1595. If for any reason you are unable to keep this appointment, we need to have 24 hours in advance notice, or you will be charged a fee up to $80.

Thank you for your time and welcome to our practice. Please take note, if you are 15 minutes late for your appointment you might have to reschedule.

Pulmonary and Critical Care Associates

Reston Office: 1860 Town Center Dr. #270 Reston, VA 20190
Lansdowne Office: 19455 Deerfield Ave. #206 Leesburg, VA 20176
PATIENT REGISTRATION INFORMATION
Patient’s Name

Last NameFirst NameMiddle Initial
Address

Street

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Home Phone
Work Phone
Cell Phone
SSN#
Gender

MaleFemale
Status

MinorSingleMarriedDivorcedWidowedSeparated
Email Address (We need for our online portal system)
Employer
Occupation
Address

Street

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse/Parent
Home Phone
Cell Phone
Emergency Contact
Relationship
Phone
INSURANCE INFORMATION
Primary Insurance
Insured’s Name

Last NameFirst NameMiddle Initial
Relationship to Patient
SSN#
Date of Birth

MonthDayYear
Do you have Secondary Insurance?

YesNo
Secondary Insurance
Insured’s Name

Last NameFirst NameMiddle Initial
Relationship to Patient
SSN#
Date of Birth

MonthDayYear
MEDICAL INFORMATION
Reason for Visit
Primary Doctor
Referring Doctor
Other Doctors Treating You
When confirming appointments, would you like a Phone call or Text?

YesNo
What number?
PATIENT AUTHORIZATION
I authorize my (or my child's) insurance benefits to be paid directly to the physician and I am financially responsible for all charges. I hereby consent to the release and re-disclosure of my medical record to enable or facilitate the collection, verification or settlement of my account for any amounts due from me or any third-party payor, health maintenance organization, insurer or other health benefit plan. This consent applies to Pulmonary & Critical Care Associates, or any of its affiliates or agents, lenders, or any third party servicer acting for Pulmonary & Critical Care Associates, or any of its affiliates.

I agree to promptly pay for services rendered for me or the patient named above. If I fail to meet my financial commitment to Pulmonary & Critical Care Associates and it becomes necessary to take action to collect my account, I agree to pay all costs and expenses incurred in the collection of my account, including attorney and collection agency fees. I further agree to pay for any missed appointments of which I did not notify the medical office within 24 hours.
Signature of Patient or parent/guardian if minor

Clear
Date

MonthDayYear
PLEASE NOTE OUR OFFICE POLICIES
- When you schedule an appointment with our practice, we set aside enough time to provide you with the highest quality care. Should you need to cancel or reschedule an appointment please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment. We reserve the right to charge for appointments cancelled or broken without 24 hour's advanced notice.
  New Patient $100
  Established Patient $50
- To our patients who have Managed Care Insurance (HMO): All patients requiring a referral MUST have a valid referral for each visit. It is the patient’s responsibility to make sure we have a valid referral. If we do not have your referral, you will need to reschedule.
**If you do not have your referral at the time of your visit, and we must reschedule your
appointment, you may be charged the under 24-hour fee.**
- Our office checks for eligibility for insurance only. It is the responsibility of the patient to contact their insurance and determine if the doctor you are seeing is in or out of network. Please note: The out-of-pocket expense is higher if you see an out of network doctor.
- Co-pays are due at the time of your visit. No Exceptions!
  - We accept the following forms of payment:
    
    Visa, Mastercard, Discover, Personal Checks, Money Orders, and Cash (exact change only)
    
    There will be a $10 administration fee added to your statement if you do not pay your co-pay at the time of your visit.
- Please be advised that if you are more than 15 minutes late for your appointment, you may have to reschedule.
- There will be a $30 fee for all returned checks.
I have read and understand the above policies for Pulmonary and Critical Care Associates.
Signature

Clear
Date

MonthDayYear
PULMONARY HEALTH HISTORY FORM
Name
Birthdate

MonthDayYear
Gender

MaleFemale
Email Address
Occupation
Preferred Pharmacy Name
Preferred Pharmacy Street Address
Preferred Pharmacy Phone
Primary Language
Race (Latino or NOT Latino?)

YesNo
GENERAL MEDICAL HISTORY (Please choose as many as necessary)

AlcoholismDiabetes Type 1MigrainesAllergies/HayfeverDiabetes Type 2Multiple SclerosisAnemiaEpilepsyMyocardial InfarctionAnxietyFractureObesityAsthmaGastric Ulcer ObesityOsteoarthritisAtrial FibrillationGastrointestinal DiseaseOsteoporosisBlood TransfusionGastroesophageal Reflux DiseasePneumoniaCADGestational DiabetesProgressive Neurological DisorderCancerGlaucomaProstate CancerChemotherapyHeart MurmurPulmonary DiseaseCardiac PacerHepatitisRadiation TreatmentCardiovascular DiseaseHigh CholesterolRheumatic FeverCHFHyperlipidemiaRheumatoid ArthritisChicken PoxHypertensionShinglesCirrhosisHyperthyroidismSleep ApneaColitisHypothyroidismSTDCOPDInsulin PumpTerminal IllnessChronic Renal FailureJoint PainThyroid DiseaseCrohn’s DiseaseKidney DiseaseTIACVAKidney InfectionTuberculosisDVTKidney StoneValvular ProblemsDepressionLeft Ventricular Systolic Dysfunction
Hospitalizations
Other Medical History
TOBACCO ASSESSMENT
Smoking Status

Current Every Day SmokerCurrent Some Day SmokerFormer SmokerNever SmokedSmoker- Current Status UnknownUnknown
Packs per Day
Smoked for how long?
Date quit smoking
Tobacco User

YesNo
SOCIAL HISTORY
Alcohol Use

Non DrinkerOccassionalSocial DrinkerModerate ConsumptionHeavy ConsumptionRecovering AlcoholicBeer DrinkerWine DrinkerNever Drank AlcoholDiscontinued
Educational level

Grades 9-12Technical/Vocational SchoolJunior CollegeAssociates DegreeBachelor DegreeMaster’s DegreePhDDoctorate
Caffeine Use

0 servings per dayOccassional1+ Servings per day2+ Servings per day3+ Servings per day4+ Servings per day
Marital Status

SingleMarriedDivorcedSignificant OtherWidowWidower
Exercise Habits

SedentaryModerate <3 x/wkModerate >3 x/wkStrenuous <3 x/wkStrenuous >3 x/wk
Occupation
SURGICAL / PROCEDURAL
Do You have Any Prior Surgical History

YesNo
If Yes Please Select

AppendectomyHerniaBreast LumpectomyHysterectomyCataract SurgeryJoint ReplacementColectomyLaparoscopySubtotal ColectomyMastectomy Right Left BilateralCone BiopsyMyomectomyD & COophorectomyEndometrial AblationOstomyGall BladderSplenectomyHeart SurgeryTonsil / AdenoidectomyHemorrhoidsTubal Ligation
Other Surgical History
PREVENTIVE CARE
Name
Flu Vaccine Date

MonthDayYear
Pneumococcal Vaccine Date

MonthDayYear
Prevnar 13 Date

MonthDayYear
Zoster Date

MonthDayYear
Help us care for you better by telling us what prescriptions and over-the-counter medications you take
Prescriptions
Over-the-counter medications, herbal remedies, and vitamins
Allergies & Reactions (environmental and medications) **Very important**
Pulmonary & Critical Care Associates, PC would like to confirm we have the most current information on file for your protection and convenience. Please complete this form and return it to our staff.
Patient Name
Date of Birth

MonthDayYear
Primary Phone Number
Are we authorized to leave a detailed voicemail?

YesNo
Would you like to have access to your patient portal?

YesNoAlready registered
Email address for access to your patient portal
Important Information Regarding the Patient Portal: By accessing this Portal, you, the patient, understand that this Patient Portal is NOT to be used for urgent or emergency situations and should be limited to non -emergency communications and requests. In case of an emergency, call 911 or go to the nearest emergency room.

PLEASE NOTE: Our preferred method of communication is through our patient portal. Medication refills and exam authorization information will be sent to your portal inbox. For those of you who do not wish to have access to your portal w e suggest you allow us to leave a detailed message as indicated above. If you do not wish us to leave a detailed message and you do not wish to use our portal, you must contact our office by telephone for this information.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO INDIVIDUALS / FAMILY MEMBERS

In accordance with Federal government policy rules implemented through the Healthcare Portability Act of 1996 (HIPAA), in order for your physician or staff of the Practice to discuss your condition with members of your family or oth er individuals that you designate, we must obtain your authorization prior to doing so. In the event of a critical episode or if you are unable to give your authorization due to the severity of your medical condition, the law stipulates that these rules m ay be waived.
Authorization

I do not authorize the practice to release any or all information concerning my medical care to any individual except as set forth above.I authorize the Practice to verbally release any or all information concerning my medical care to the following individuals.
Name
Relationship to Patient
Name
Relationship to Patient
Patient Signature

Clear
Date

MonthDayYear
Witness Signature

Clear
Date

MonthDayYear
AUTHORIZATION TO RELEASE FINANCIAL INFORMATION TO INDIVIDUALS / FAMILY MEMBERS
Name
Relationship to Patient
Name
Relationship to Patient
Patient Signature

Clear
Date

MonthDayYear
Please sign below acknowledging your receipt of our notice of privacy practices.
Name
Patient Signature

Clear
Date

MonthDayYear
AUTHORIZATION TO OBTAIN OR RELEASE OF MEDICAL RECORDS FROM MEDICAL PROVIDERS

I hereby authorize Pulmonary & Critical Care Associates (the Practice) to obtain any and all medical records concerning my care from any physician, hospital or other health care professional that has provided medical care to me in the past.

I also authorize the practice to release any and all medical records concerning my care to any physician, hospital or other health care professional providing care to me at any time. Additionally, I authorize the Practice to release any and all medical records concerning my care to Medicare, Medicaid, any Insurance company, third party administrator, or managed care company.
Patient Signature

Clear
Date

MonthDayYear
Name
Date of Birth

MonthDayYear
Should be Empty:

PATIENT REGISTRATION INFORMATION

INSURANCE INFORMATION

MEDICAL INFORMATION

PATIENT AUTHORIZATION

PLEASE NOTE OUR OFFICE POLICIES

PULMONARY HEALTH HISTORY FORM