patient registration · 2020. 7. 6. · ear yes no explain changes in hearing cotton swab use...
Post on 19-Sep-2020
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1016 MAIN AVE CLIFTON, NJ 07011 Tel: 973-546-5700 Fax: 973-546-8898
PATIENT REGISTRATION
PLEASE PRINT AND COMPLETE ALL ENTRIES PATIENT NAME (LAST -- FIRST -- MIDDLE INITIAL) ADDRESS
CITY, STATE ZIP HOME PHONE CELL PHONE
PATIENT DATE OF BIRTH PATIENT SSN SEX Male Female Transgender Other
MARITAL STATUS Single Married Other______________
RACE American Indian or Alaska Native Pacific Islander Asian White Black or African American Other Hispanic
PRIMARY LANGUAGE English Spanish Russian Korean Other ______________
ETHNICITY Hispanic or Latino Non Hispanic or Latino Other _____________
PATIENT EMPLOYER NAME PATIENT EMPLOYER ADDRESS (STREET ADDRESS - CITY - STATE - ZIP) EMPLOYER PHONE
INSURED/RESPONSIBLE PARTY INFORMATION RELATION TO PATIENT: spouse parent guardian NAME (FIRST -- LAST -- MIDDLE INITIAL) ADDRESS (if different from patient)
HOME PHONE WORK PHONE SSN BIRTH DATE EMPLOYER
INSURANCE INFORMATION PRIMARY INSURANCE NAME ADDRESS (STREET - CITY - STATE - ZIP) PHONE
GROUP NUMBER ID NUMBER EMPLOYER EMPLOYER PHONE
SECONDARY INSURANCE NAME ADDRESS (STREET - CITY - STATE - ZIP)PHONE
PHONE
GROUP NUMBER ID NUMBER EMPLOYER EMPLOYER PHONE
VISION PLAN ID NUMBER
IN CASE OF EMERGENCY CONTACT RELATIONSHIP PHONE NUMBER
PRIMARY CARE PHYSICIAN NAME ADDRESS
CITY, STATE ZIP PHONE FAX
REFERRING DOCTOR PHONE
PHARMACY INFORMATION NAME PHONE
ADDRESS
23 W. PALISADE AVE ENGLEWOOD , NJ 07631 Tel: 201-408-4441 Fax: 201-408-4452
Rev: 4/10/19
HIPAA: PATIENT RIGHTS AND RESPONSIBILITIES
It is the policy of NJ Eye and Ear to treat all patient information confidentially. This includes patient records and conversations. We will investigate any reported violation of this policy. We make every effort to provide our patients with an environment, which is safe, private and respectful of our patient’s needs. We will do everything we can to see that your experience with us is professional in every way.
NJ Eye and Ear is committed to your participation in care decisions. As a client, you have the right to ask questions and receive answers regarding the course of clinical care recommended by any of our health providers, including discontinuing care. We urge you to follow the healthcare directions given to you by our providers. However, if you have any doubts or concerns, or if you question the care prescribed by our providers, please ask. By signing this form, I agree that NJ Eye and Ear may send automated text messages to my cell phone for appointment reminders, news and promotional information. I understand that standard text messaging rates will apply to any message received from NJ Eye and Ear. I understand that I may revoke this permission at any time by notifying NJ Eye and Ear in writing.
Patient Rights: 1. The patient has the right to receive information from health providers and to discuss thebenefits, risks, and costs of appropriate treatment alternatives. Patients should receive guidance from their health providers as to the optimal course of action. Patients are also entitled to obtain copies or summaries of their medical records, to have their questions answered, to be advised of potential conflicts of interest that their health providers might have, and to receive independent professional opinions. 2. The patient has the right to make decisions regarding the health care that is recommended byhis or her health provider. Accordingly, patients may accept or refuse any recommended medical treatment. 3. The patient has the right to courtesy, respect, dignity, responsiveness, and timely attention tohis or her needs, regardless of race, religion, ethnic or national origin, gender, age, sexual orientation, or disability. 4. The patient has the right to confidentiality. The health provider should not reveal confidentialcommunications or information without the consent of the patient, unless provided for by law or by the need to protect the welfare of the individual or the public interest. 5. The patient has the right to continuity of health care. The health provider has an obligation tocooperate in the coordination of medically indicated care with other health providers treating the patient. The health provider may discontinue care provided they give the patient reasonable assistance and direction, and sufficient opportunity to make alternative arrangements.
Rev: 4/10/19
Patient Responsibilities: 1. Good communication is essential to a successful health provider‐patient relationship. To theextent possible, patients have a responsibility to be truthful and to express their concerns clearly to their health providers. 2. Patients have a responsibility to provide a complete medical history, to the extent possible,including information about past illnesses, medications, hospitalizations, family history of illness and other matters relating to present health. 3. Patients have a responsibility to request information or clarification about their health statusor treatment when they do not fully understand what has been described. 4. Once patients and health providers agree upon the goals of therapy, patients have aresponsibility to cooperate with the treatment plan. Compliance with health provider instructions is often essential to public and individual safety. Patients also have a responsibility to disclose whether previously agreed‐upon treatments are being followed and to indicate when they would like to reconsider the treatment plan. 5. Patients should also have an active interest in the effects of their conduct on others and refrainfrom behavior that unreasonably places the health of others at risk.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent in writing, signed by you. However, such revocation shall not affect any disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The patient understands that: Protected Health Information may be disclosed or used for treatment, payment of health care operations. The Practice has a notice of Privacy Practices and that the patient has the opportunity to review this Notice. The Practice reserves the right to change the Notice of Privacy Policies. The Patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The Patient may revoke this Consent in writing at any time and all future disclosures will then cease. The practice may condition treatment upon the execution of this Consent.
Rev: 4/10/19
PATIENT FINANCIAL RESPONSIBILITY & AUTHORIZATION
Thank you for choosing NJ Eye and Ear for your medical needs. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.
Patient Financial Responsibilities:
The patient (or patient’s guardian, if a minor) is ultimately responsible for the paymentfor treatment and care.
We will bill your insurance for you. However, the patient is required to provide the mostcorrect and updated information regarding insurance.
Patients are responsible for payment of copays, coinsurance, deductibles and all otherprocedures or treatment not covered by their insurance plan.
Copays are due at the time of service.
Coinsurance, deductibles and non‐covered items if not available at the time of service aredue 30 days from date of service/ receipt of billing.
Patients may incur, and are responsible for payment of additional charges, ifapplicable. These charges may include‐ charge for returned checks ‐ $30.00
We charge a No Show fee of $25.00 after a patient does not attend a confirmedappointment.
Patient Acknowledgement and Authorization:
We respect patient confidentiality and only release personal health information about you in accordance with the State and federal law. The attached notice describes our policies related to the use of the records of your care and how you may get access to this information. Please review this policy carefully.
By my signature below, I acknowledge that I have received and read the privacy notice provided by NJ Eye and Ear. I hereby authorize NJ Eye and Ear and the physicians, staff, and hospitals associated with NJ Eye and Ear to release medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, third party payers, and/or other physicians or healthcare entities required to participate in my care. This Consent was signed by:
Patient Name: ______________________________________
Patient/Guardian Signature: ___________________________ Date: ____________________
Release of Medical Records
Patient Name: __________________________________ Date of Birth: ________________
Patient Address: ________________________________________________________________
Phone Number: _______________________________
A mutual patient of ours, _________________________, is requesting their medical records to
be sent to New Jersey Eye and Ear, so we may continue in aiding in their health and care. By
signing below, the above named patient gives permission to release all information our office
may need.
Thank you for your assistance with the request.
Doctor’s Name / Facility Name: __________________________________________________
Office Address: _______________________________________________________________
Phone Number: ________________________ Fax Number: __________________________
Please send records to 201-408-4452
Thank you.
__________________________ ______________________
Patients Authorization Signature Date
__________________________ ______________________
Witness Date
Kevin Ende, M.D.
Director of Otolaryngology (Ear, Nose and Throat)
Facial Plastic and Reconstructive Surgery
Hair Restoration
23 W. Palisade Ave. Englewood, NJ 07631 • P:201-408-4441 • F:201-408-4452
Ear YES NO Explain
Changes in hearing
Cotton swab use
Discharge
Ear trauma
Earache
Itching
Ringing in the ears
Use of Hearing aid
Vertigo/Dizziness
Positive result on hearing loss test
Head and Neck
Cancer of head and neck
Daytime sleepiness
Facial numbness
Facial swelling
Headaches
History of trauma
Mouth and throat
Acid reflux
Coughing
Bleeding gums
Dental issues
Difficulty swallowing
Hoarseness/Vocal Changes
Oral lesions/Masses
Painful Swallowing
Sensation of fullness
Sore throat
Throat clearing
Tonsil infection
Nose and Sinus
Itching
Lack of Smell
Nasal trauma
Nose bleeding
Obstruction of airflow
Post nasal drip
Runny nose
Seasonal allergies
Sinus pain
Sinusitis
Sneezing
Snoring
Watery eyes
Allergy Testing
We offer both surgical and nonsurgical cosmetic treatments such as: Botox, Fillers, Facial Peels, Cosmetic Facial Surgery,
Hair Restoration and Laser Hair Removal
Have you ever had any cosmetic treatments?
Are you interested in hearing about our cosmetic treatments?
Which Cosmetic treatments are you interested in:
Circle the areas you are interested in enhancing
For more info visit DrEnde.com or scan the qr code while you wait
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