Document 6636

Patient Medical Information
Kendall L. Wise, MD
(239) 261-5400
N.. Naples FL 34102 (239) 261-4387
A Division of 21 st Century Oncology, LLC
1044 Goodlette Road
Today's Date:
Patients Date of Birth:
Patient Name (Legal):
First
Middle
Last
Allergies (Food or Drug)
Please list all medications you are currently taking: (Include dosage and frequency)
Medication
Dosage & Frequency
PATIENT MEDICAL HISTOKY
Renal Cancer
Prostate Cancer
Bladder Cancer
He~naturia
Diabetes
Ulcer
Arthritis
Cancer
Renal Failure
Stones
Recurrent UTI
Prostatitis
Stroke
Asthma
COPD
Pulmonary Embolism
Headaches
PATlENT SURGICAL HISTORY
Colitis
Gallbladder Problems
Ulcer
Congest i~ e Heart Failure
Myocardial Infarction (Heart Attack)
Cardiac Problems-list type:
Arrhythmia
High Blood Pressure
Diverticulitis
Seizure
Depression
Hepatitis
Liver Problems
Anemia
leukemia
Thyroid Disease
PLEASE INDICATE "L" (Left)"Rt'(Right)OR "BI" {bilateral-both sides) and approximate date
L R Bi
Cataract
Appendectomy
Lung
Arthroplasty
Heart
Kidney
Stone
Bladder
Prosthesis
Incontinence
Colon
Removal of Gallbladder
Hernia
FAMILY HISTORY
Relationship to you (exarnp1e:brother)
Cancer-List Type:
Prostate- Cancer
Stones
Heart Disease
Diabetes
Strokes
Hypertension
MALE
Prostate
Testis
Vasectomy
FEMALE
Ovarian Syndrome
Uterine Surgery
Breast Surgery
# of Pregnancies
Cesarean Section
Hysterectomy
EEI
SOCIAL HISTORY
Language
Race
White
Black or African American
American Indian or Alaska Native
English
Spanish
French
German
Portuguese
Russian
Chinese
lapanese
Italian
Other
Eskimo
Hispanic or Latino
Asian
Native Hawaiian or Pacific Islander
Unknown
Other
Ethnicity Non-Hispanic or Latino
Hispanic or Latino
MARITAL STATUS
Single
SMOKING HISTORY
No History
Currently Smoke
Former Smoker
# Of Packs Smoked/Day
Widowed
Divorced
Married
Spouse Name:
ALCOHOL USE
YES
Types of alcohol consumed:
Drinking Habits:
REVIEW OF SYSTEMS
Constitutional Symptoms:
Chills
Fever
Weight Loss
Eyes:
Blurred Vision
Double Vision
Cataracts
Ear/lVose~hroat/Mouth:
Nasal Stuffiness
Hearing Loss
Sore Throat
Curdiuvrrscular:
Chest Pain
Irregular Heartbeat
Swollen Ankles
Respiratory:
Shortness of Breath
Wheezing
Cough
PATIENT SIGNATURE:
CAFFEINE How many caffeinated beverages per day?
I
I
NOTANY MORE
Beer
Light
social
NEVER
Wine
Other
Moderate Excessive
Gastrointestinal:
Abdominai Pain
Nausea /Vomiting
Change in Bowels
Genitourinaty :
Blood In Urine
Incontinence
Painful Urination
Musculoskeletal:
Chronic Back Pain
Chronic Neck Pain
Sore Muscles
Neurologicrrl:
Dizzy Spells
Numbness/Tingling
Hematologic/Lymphatic:
Abnormal Bleeding
Swollen Glands
Transfusions
New Patient Information Sheet
(239) 261-5400
KendalI L. Wise, MD
1044 Goodlette Road N.,Naples FL 34102 (239) 261-4387
A Division of 2lst Century Oncology, LLC
TODAY'S DATE:
i
PRIMARY CARE PHYSICIAN:
REFERRING PHYSICIAN:
HOME #:
(
1
CELL#:
(
)
NAME
First
Last
Middle
DATE OF BIRTH:
/
1
SOC. SEC. #
ADDRESS
Street
City
State
Zip
City
State
Zip
OUT OF AREA ADDRESS
Street
GENDER: (cirde one)
MARITAL STATUS; {circle one)
Male I Female
Married I Single / Divorced I Widowed
ETHNICITY: (circle one)
HispaniclLatino / Other I Not RepofiedlRefused
RACE: (circle one')
White (Caucasian) / BlacWAfrican American / Asian / Native American
American IndianlAlaskan Native / Native Hawaiian I Pacific Islander
Asian Pacific American / Subcontinent Asian American I Hispanic
Caucasian Non-Hispanic / Black Non-Hispanic / More than 1 race / Other Race
PHARMACY INFORMATION
Pharmacy Name:
Pharmacy Location:
Pharmacy Pbone #
PRIMARY 1NSURANCE INFORMATION
Name of Company:
Group:
Insured's/Guarantor Name:
Guarantor Date of Birth:
SECONDARY INSURANCE INFORMATION
Name of Company:
Group:
Insured'y/Guarantor Name:
Guarantor Date of Birth:
ADDITIONAL 13RD)INSURANCE INFORMATION
Name of Company:
Croup:
Insured'slGuarantor Name:
Guarantar Date of Birth:
Use this form during patien1 r e g ~ s t r a t ~ aton dbcument any patient requests to authorize and r e s t r ~ c thow [her
health informath is disclosed to frcends/farnily memberstothers. Use also to document any {€quests fw
c o n f i d e n t i a l cornmunrcationa
Patient Authorization for Genetal Disctosure andlor
Request for Restrictions of Protected Health Information
and Request for Confidential Communications
1 hereby request the fo~lowrnguse cr disclosure of m f health infcfmaticn as descfibeo below
Patlent M a m t
I h.le0;sal Rec7rd Number
Date of Binh
'
I
ioaress iSl(ee1. 21ir, Stale.
I
Telephone hurnDer
Code)
I
1 requesl that my heelb iniormal~onor m e d a l b~lhngrcord b1 -e~d16cl0scd
- 1 . ~ 1 c i r ~or
se .
I Alrrhorrrd U I names
~
Irsted aelow 10 haw access to my medical
Inf~rmar~on.
These people may call and speak with Ihs nurseldocfn~
about m), case. I have Ihe right to terminate mi$ agreemen( el any
time by infotmmg a (flpfssonlaliue of the physicran office
'bb NOT discuss or provide informalion lo Ihe fallowing individua,~
or enlirirs:
Authorized Name
i
'I requesl the use of ONLY lhe follawl~gaddress
andlor phone numbtr(s) ro conlacl me regarding my health or bill~ngrnformation.
Patient Rtghls: Your physiclvn office maxt permkt psllenls lo reque$[rtsirictiova oflheir protected hcallh ~nlorn,atrurh.
Patlenls may teqUeSr
reslriclion of UCRE and disclosures o i prolscled health inlorpalion to carry owl Irealment, payment, and healthcafe operations; discIosures lo a
family member, OlhW relalive, dose personal friend. or any *!her person ident~tiedby Ihe palienl of pcotected heallh ~nfomaliondireclly releven(
l o such person's 1nuolv6mentwth m e patlenl's care: and diislbzures uf protecied hcrlrh ~nl~rrrdalivn
to notify or 3siis1 \nme not\dtation o( a
family member, a personal rspresenlatrve or anotner parson r e ~ p o n s r ~tor
l e Ihe care of me pallent or the pslien'z localion, general cundilion, or
death. AH reqvesls for restrlcraons must be submitted in wrifino.
Physlelan Ofi~ceR e s p ~ n s ~ b r l i t t sYour
s : physicIan omce 13 nor requrred lo grant most re:lr~cliono and rs prscrrrded from granling restrictions
Ihaf would vrolare [he law. H we agree ro the reslricllon, we wlil comply n l l n 11unlots ycu ask lo lerrnlnale the- rerlriction or w e nol~fyvou !hat wc
I r e lermtnatina Ihe agreement. If you reqdrd ernstgenq treslment, we may release Ihe reslrided information wrlhout your consenl ifil Is rleeded
10 provide Iha~trealment.
Dale
jignature a i Patient or Legal Represenhh~e
A
It Signed
I
by Legal Reptasanlal~ve,Refallonshiplo Paltsnl
~ISQOSlTlOM
of PATlEHf REQUEST: The above request fw r+str\clionof heakh m f m a t h n by the above-nar,edpatient has
been'
'Granted
'If GRANTED,
Opnitcl
an Alen must be entered inlo all eleclr6ntc medlcal records and/or practrce management (billing) sysremis)
Reason(s) for D e n ~ a tif, Applicable
Physician Office Representative'
-
+
Oale;
I
.
-.
-
.
--- -
-
Oncology
LeelCollier Counties, Florida Market
Patient Protection and Affordable Care Act of 2010
Patient Disclosure for Diagnostic MRI, PET or CT Services
Dear Patient,
If your physician determines that a referral for diagnostic MRI, PET or CT
services is appropriate as a part or your medical evaluation and treatment; we
may have these services available at one of our locations. We will provide you
information about those options.
You, however, have the freedom to choose the supplier for this service. To the
best of our knowledge, the following providers furnish these services in the area
Name: Radiology Regional Centers
Address: 6100 Winkler Rd, Ft. Myers. FL 33919
Name: Advanced Radiology Imaging Associates, LLC
Address: 13731 Metropolis Ave, Ft. Myers, FL 33912
Name: Florida Radiology Consultants
Address: 6311 Southpointe Blvd, Ft. Myers, FL 33919
Name: Naples Diagnostic Imaging Center
Address: 31 1 North Tarniami Trail, Ste 104, Naples, FL 341 02
Name: Radiology Regional Centers
Address: 700 Goodlette Rd, Naples, FL 34102
1 have read and understand this notice
Patient Name (Printed):
Patient Signature:
Form # RTMS 04 1 030 0 V . l
Date:
Date: 01/10/201 1
Kendall L. Wise, M.D.
1044 G d l e t t e Rd.
N. Naples, FL 34102
Phone (239)261-5400 Fax (239)261-4387
AUTHORIZATIONS AND PAYMENT AGREEMENT
When assignment is accepted, I hereby authorize payment directly to Kendall Wise, for benefiis
(including Medicare benefits or Major Medical) payable under the terms of my insurance or governmental
coverage for any sewices furnished me by Kendall Wise. (Void aft^ Decemher 31 of this calendar year on
Medical Claims.)
Upon receipt of a written request for release of medical information, I hereby authorize Kendall Wise to
mlease information acquired in the course of my examination or treatment.
I hereby authorize any physician, hospital, or medical facility to provide information on my medical history
and treatment to Kendall Wise.
I hereby authorize any holder of medical or other information about me to release to the Social Security
Administration and/or the State of Florida or their intermediary or fiscal agent any information needed for
Medicare or Medicaid claims.
I hereby authorize Kendall Wise to receive "Explanation of Medicare Benefits" advisements for
non-assigned Medicare claims on my behalf directed from the Medicare intermediary.
I hereby certify that the information given by me in applying for payment under the Medicare or Medicaid
programs is correct.
I hereby authorize photocopies of this form to be as valid as the original.
1 hereby agree to be responsible for the payment of this patient's account.
PATHOLOGY CONSENT: I hereby authorize the physicians of Kendall Wise to order any pathology testing
they deem necessary in connection with off ice visits or surgeries.
OUR PAYMENT POLICY* PLEASE NOTE
You are responsible directly to the office for payment of your account, regardless of the status of medical
or liability insurance claims. Mice charges should be paid on the date incurred. All other charges are
payable within 60 days, unless you arrange an extended payment plan. A~countswith charges 60 days or
older will be subject to a rebilling fee. The undersigned hereby obligates himherself to pay the account for
medical sewices rendered. If this account is referred to an attorney or collection agency for coliection, the
undersigned shall pay for reasonable attorney's fees, collection expenses, court costs and recording fees.
Upon mquest, special consideration may be extended in the event of hardship. To avoid misunderstandings,
we invite you to discuss problems with our practice manager.
Standardized insurance forms are completed as a courtesy to you without c h q e . The office does not
accept responsibility far collecting your insurance claims or negotiating settlement on a disputed claim.
Theg&eiima% mguktbm andpokcras r e g d i n g ttm m d p t ofpayment Irwn M e d b or M e d M a m [email protected] on my #&&m
claim whwe the
or
daccepts ass&nmant of benem. If you haw a question or need tWw W t i o n rn
~ p a y m e n t spAwielet
,
us know.
w M&&d
OAT€:
SIGNATUREOF PATIENTAND/OR G U M O R
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