New Patient Packet and Health Questionnaire

HEAD & NECK ASSOCIATES OF ORANGE COUNTY, INC.

Bredenkamp | Cho | Crockett | Jakobsen | Luu | Mundi | Supance | Thompson | Wells | Wohlgemuth

PATIENT INFORMATION

Name: Birth Sex: M F

Address:

Birthdate: SS#: Marital Status: S M D W O

Preferred Contact

Phone Numbers: 1. 2.

E-mail Address: Primary Language:

Race: African American American Indian Asian Caucasian Pacific Islander Other

Ethnicity: Hispanic/Latino Non-Hispanic/Latino

Referring Physician: Office Number:

Office Location:

Emergency Contact: Phone: Relationship:

Please print the name and relationship of the persons you authorize to receive protected health care information:

Name: Relationship:

Name: Relationship:

INSURANCE POLICY INFORMATION

Policy Holder’s Name:

Birthdate: SS#: Relationship to Patient:

Address:

Primary Insurance Co: Policy Holder’s Employer:

Policy Holder’s Name: Policy Holder’s Birthdate:

Policy #: Group #: Relationship to Patient:

Secondary Insurance Co: Policy Holder’s Employer:

Policy Holder’s Name: Policy Holder’s Birthdate:

Policy #: Group #: Relationship to Patient:

ASSIGNMENT OF BENEFITS / RELEASE OF INFORMATION

I assign and request payment of medical benefits be made to HEAD AND NECK ASSOCIATES OF ORANGE COUNTY, INC. for medical services rendered. I authorize the release of medical information necessary to process my claim. I also authorize that I may be contacted via any of the above contact information I have provided. I have read the Financial Policies and understand that I am financially responsible for any non-covered services.

FINANCIAL POLICIES

Head and Neck Associates will submit claims to your insurance company for all medical services rendered. We will attempt to verify eligibility and benefits with your insurance company; however, this verification is not a guarantee of payment. Any expenses deemed not covered by your insurance company will be your financial responsibility.

All monies owed by the patient, i.e., office visit copayments and non-covered services or supplies are due at the time of service. Also, when applicable, coinsurance percentages and/or deductibles may be collected at the time of service. Please be aware that this office will bill only for the physicians’ services. Any other services related to your office visits, i.e., laboratory, radiology or pathology will be billed by the facility providing these services.

In order to properly evaluate our patients, it is often necessary for the physician to perform an in-office procedure such as, but not limited to:

fiberoptic laryngoscopy

biopsies

ultrasounds

fiberoptic nasal endoscopy

hearing tests

CT scans

These services are billed as an additional charge from the office visit and additional coinsurance and/or deductible amounts may apply. Although these services are done in the office, they are often labeled as “surgery” on your insurance company explanation of benefits. If you have any questions regarding the necessity of any of these services, please direct them to your physician at the time of service.

PLEASE INITIAL THAT YOU HAVE READ AND UNDERSTAND THE ABOVE:

It is your responsibility to provide Head and Neck Associates with proof of insurance and an authorization number or referral when applicable. If these items are not provided we ask that you pay in full at the time of service.

The contract between Head and Neck Associates and your health plan, as well as the contract between you and your health plan requires that you make payment in full of all co-payments and deductible amounts deemed to be your responsibility upon claims processing. Additional discounts are forbidden by contract unless financial hardship is documented in writing by the patient.

Our office accepts the following forms of payment: most major credit cards, cash, and personal checks. A $20 service charge will be assessed to your account for any check returned by your bank.

ACKNOWLEDGEMENT OF RECEIPT
NOTICE OF PRIVACY PRACTICES

I hereby acknowledge receipt of the Notice of Privacy Practices being adhered to by Head and Neck Associates of Orange County. The Notice of Privacy Practices is supplied in accordance with the Privacy rule that is an integral part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

A physical copy of the HIPAA Acknowledgement can be provided upon request.

HEAD & NECK ASSOCIATES OF ORANGE COUNTY, INC.

Date:

Page 1 of 2

Completed by Patient or

Name: Date of Birth:

Primary Care Physician: Pharmacy:

Doctor who referred you (first and last name): Office Phone:

Other physicians caring for you: Height: Weight:

Reason for Visit: Date of Injury:

Have you had an Influenza Vaccination (Flu Shot)? YES NO

If yes, please indicate: Date performed Performed by

*65 years or above, have you received the Pneumococcal Vaccine (Pneumovax Injection)? YES NO

If yes, please indicate: Date performed Performed by

Medications: Please list medications and dosages NO medications

1. 4.

2. 5.

3. 6.

Allergies: Please list allergies to medications NO allergies to medications

1. Reaction:

2. Reaction:

Please SELECT symptoms that apply to why you are being seen by us today:

Constitutional: Abnormal weight change Fever Chills Fatigue

Respiratory: Cough Snoring Wheezing Shortness of breath

Cardiovascular: Chest Pain Palpitations

Gastrointestinal: Abdominal Pain Constipation Diarrhea Vomiting

Neurological: Trouble walking Non-restorative sleep Fainting Tingling

Psychological: Increased anxiety Depression Behavior changes

Ear/Nose/Throat: Hearing Loss Ear Pain Hearing noises in ear Dizziness Trouble swallowing Change in Voice Throat Pain Post-nasal drip Nasal Congestion Headache Jaw pain

Musculoskeletal: Neck stiffness Increased muscle pain Increased joint pain Muscle weakness

Genitourinary: Change in urinary color Increased urgency Blood in urine Pain when urinating

Allergy/Immunology: Hay fever Hives Food allergies

Head and Neck Associates of Orange County, Inc.

Date:

Page 2 of 2

Completed by Patient or

Name: Date of Birth:

Past Medical History: Please SELECT if you have been diagnosed or had any of the following:

Anesthesia complications Anxiety Asthma Bleeding Disorders

Congestive Heart Failure Cancer: Type Diabetes: Type

Emphysema Epilepsy Glaucoma Headaches, Migraines

Heart Attack Hepatitis High Blood Pressure HIV

Hyperthyroidism Hypothyroidism Irregular Heartbeat Immune Suppression

Kidney Disorders Reflux (GERD) Sleep Apnea Stroke

Please list any other medical conditions:

Past surgeries with approximate dates:

1. 4.

2. 5.

3. 6.

Family History:

Social History:

Have you ever used tobacco products? YES NO

If so, please SELECT which apply: Cigars Cigarettes E-cigarettes Hookah Chew Vape

How much per day? How many years? Age stopped:

Do you drink alcohol? YES NO How many drinks per day?

Please SELECT which drugs you have used: Cocaine Ecstasy Heroin LSD Marijuana Other

Describe your exercise level: Sedentary Moderate Vigorous

What type of exercise?

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