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Standard Authorization of Use and Disclosure of PHI
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WYOMING SURGICAL ASSOCIATES, P.C.
James A. Anderson, MD
Todd H. Beckstead, MD
Brock A. Anderson, MD
Clayton E. Turner, MD
Aimee E. Gough, MD
Hillary C. Morrison, DO
Download PDF
MEDICATIONS CURRENTLY TAKING
Date:
Date Format: MM slash DD slash YYYY
Patient's First Name:
Patient's Last Name:
Date of Birth:
Date Format: MM slash DD slash YYYY
Are you currently taking any blood thinners?
Yes
No
Are you diabetic?
Yes
No
Please list all allergies:
What Pharmacy do you want us to send prescriptions to?
Name of Medication, Dose (mg), How often do you take?
(One medication per line)
Date:
Date Format: MM slash DD slash YYYY
Referring Dr or Primary Care Dr if not referred:
Patient Legal Name:
*
First
Last
Age:
Birth date:
Mailing Address:
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone:
*
Cell Phone:
Social Security #:
Email Address:
*
Marital Status:
Single
Married
Divorced
Widowed
Male
Female
Employer:
If retired, please put retired/date of retirement. If student, please put name of school/part or full time
Employer Phone Number:
SPOUSE INFORMATION
Spouse Name:
First
Last
Age:
Birth Date:
Date Format: MM slash DD slash YYYY
Social Security Number:
Employer:
(If retired, please put retired/date of retirement)
Employer Phone Number:
Cell Phone:
RESPONSIBLE PARTY (IF OTHER THAN PATIENT PLEASE FILL IN BELOW)
Name & Relationship:
Social Security Number:
Mailing Address:
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Birth Date:
Date Format: MM slash DD slash YYYY
Employer:
Phone Number:
EMERGENCY INFORMATION
Name of friend or relative:
Relationship:
Phone Number:
Address:
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Please note that we now require a copy of your Medicare, Medicaid and or Insurance Card to verify the mailing address, phone number and the spelling of your name as shown on each individual card.
We can not file insurance claims for you without the birthdate and social security number of the policy holder.
We are also requiring a copy of your driver’s license or other picture id that includes your signature. This is to be able to verify your identity in the event of requests for release of Private Health Care information.
We appreciate your help and understanding of these requests.
PRIMARY INSURANCE INFORMATION
Primary Insurance Carrier:
Insurance Policy Number:
Insurance Group Number:
Insurance Company Address:
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Insurance Company Phone Number (member services):
Name of Insurance Policy Holder:
Relationship of Policy Holder to you:
Policy Holder’s Birth date:
Date Format: MM slash DD slash YYYY
Policy Holder’s Social Security Number:
SUPPLEMENTAL INSURANCE INFORMATION
Supplemental Insurance Carrier:
Supplemental Insurance Policy Number:
Supplemental Insurance Group Number:
Supplemental Insurance Company Address:
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Name of Supplemental Insurance Policy Holder:
Relationship of Supplemental Policy Holder to you:
Supplemental Policy Holder’s Birth date:
Date Format: MM slash DD slash YYYY
Supplemental Policy Holder’s Social Security Number:
AUTHORIZATION AND FINANCIAL UNDERSTANDING
By accepting the medical services provided to me by James A. Anderson, MD, Brock A Anderson, MD Todd H. Beckstead, MD, Mattew P. Doering, MD, Kevin D. Helling, MD, Aimee Gough MD, and/or Clayton E Turner, MD or any other employee of the corporation, I agree to be financially responsible for the charges billed by Wyoming Surgical Associates, P.C. for those services.
f there is medical insurance which will cover all or a portion of the charges I incur by James A. Anderson, MD, Brock A Anderson, MD, Todd H. Beckstead, MD, Matthew P. Doering, MD, Kevin D. Helling, MD, Aimee Gough, MD and/or Clayton E Turner, MD or any other employee of the corporation for my treatment, I hereby assign those insurance benefits to Wyoming Surgical Associates, P.C., and authorize the insurance benefits to be paid directly to Wyoming Surgical Associates, PC. This assignment will remain in effect until revoked by me in writing.
I understand and agree that if my insurance benefits do not cover all of the charges for my treatment, including what my insurance company classifies as over reasonable and customary charges, that I am responsible to pay any outstanding balances. I further agree that in the event of non-payment to Wyoming Surgical Associates, PC of any amounts due under this agreement I will pay interest thereon at the rate of 1.75% per month and pay all of Wyoming Surgical Associates, PC reasonable legal fees, attorney fees and court costs that may be incurred. I agree that in the event this agreement is assigned to a collection agency for collection I promise to pay a collection fee of 35% of the unpaid balance due which is in addition to the unpaid balance due under this agreement.
I understand that it may be necessary for Wyoming Surgical Associates, P.C. to disclose medical information about my treatment to my insurance companies, employer, or third-party payers in order to process a claim on my behalf.
A photocopy of this assignment and financial agreement is to be considered as valid as the original.
I understand that it is my responsibility to contact my insurance company for pre-authorization on procedures.
I hereby give my permission for any employee of Wyoming Surgical Associates, PC as well as any physician’s office or facility to which I may be referred to contact me at:
My work phone
My work phone and leave a message to call back
My home phone and leave a message to call back
My home phone and leave a detailed message on either an answering machine or with whoever answers the phone.
Any other verbal or written contact I have provided to your office for both call back and detailed messages.
Please uncheck any of the below that you do not want us to do.
Chief Complaint (symptoms):
HISTORY OF PRESENT ILLNESS:
How long have you had this problem?
What makes your problem worse?
What makes your problem better?
REVIEW OF SYSTEMS:
Check
any problems that you have experienced recently or for prolonged periods in the past:
General:
Weight loss
Weight gain
Weakness
Fever
Chills
Night sweats
Skin:
Rash
Non-healing wounds
Eyes:
Blurred vision
Loss of vision
Glaucoma
Ears
Deafness
Ringing
Discharge
Pain
Nose
Bleeding
Discharge
Obstruction
Mouth
Bleeding gums
Sore areas
Open wounds
Throat:
Recent sore throat
Difficulty Swallowing
Hoarseness
Tonsillitis
Neck
Pain
Stiffness
Breasts:
Discharge
Lumps
Pain
Bleeding
Lungs:
Cough
Sputum change
Coughing of blood
Shortness of breath
Heart:
Pain in chest
Swelling of legs
History of Rheumatic Fever
Fluttering of heart
Heart murmur
Vascular:
Pain or cramps in legs after walking
Varicose veins
DVT (Blood Clot)
Gastrointestinal:
Nausea Vomiting
Vomiting of blood
Heartburn
Black stools
Dark urine
Hernia
Urinary tract:
Pain on urination
Dribbling
Loss of urine
Blood in urine
Musculoskeletal:
Broken bones
Arthritis
Stiff joints
Muscle weakness
Slurred speech
Neurological:
Seizures
Numbness
Paralysis
Headache
Psychiatric problems:
Depression
Nervousness
Altered sleep (more)
Altered sleep (less)
Change in appetite
PAST MEDICAL HISTORY:
Heart Disease (including heart attack, angioplasty, coronary bypass surgery)?
Yes
No
Any other medical or health problems?
Past surgeries:
Social History:
Married
Single
Divorced
Widowed
Number of children?
Type of employment?
Habits?
Smoke
Chewing Tobacco
Alcohol
Drug Use
Exercise
Family Medical History:
Mother?
Living
Deceased
If deceased, cause of death?
Father?
Living
Deceased
If deceased, cause of death?
History of any of the following in family?
Heart Disease
Diabetes
Lung Disease
Breast Cancer
Colon Cancer
Other Cancer
Other cancer, if selected: