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Welcome to our practice!
Please complete the attached forms before arriving to your appointment. Please
arrive 15 minutes prior to appt. This allows us time to input the information into your
chart. If forms are not completed, your appointment will be rescheduled. If you
need help with any of the forms, please do not hesitate to call our office. We will try to
make it as easy as possible for you.
If you are coming to us from a prior SK\VLFLDQ¶VRIILFH; we suggest you have your
medical records transferred to our office before your scheduled appointment, so that
continuity of care is maintained(especially labs and x-rays).
There are so many different insurances and they are constantly changing. It is important
that you bring your insurance cards with you to every visit. If your insurance requires
a co-pay or deductible, payment is due at the time of the visit.
You will be contacted 1-2 days in advance to remind you of your appt. If you need to
cancel your appointment, please do so 24 hours in advance. This allows us to free up
appointment slots to meet the needs of all our patients. If we do not receive notification
of cancellation you will be billed $40.00.
RHEUMATOLOGY ASSOCIATES OF NORTH TEXAS, PA
REGISTRATION FORM (Please Print)
4461 Coit Rd., Suite 402 Frisco, TX 75035-0521 (214) 297-0099 Fax (214) 297-1102
PATIENT INFORMATION Legal name:
Last: First: Middle:
Gender: M / F
Mr. Mrs. Miss/ Ms.
Marital Status (circle one): Single Widowed Married Partner Divorced Separated Do you want access to
your records online? Email address: Birthplace: Date of Birth: Age: SSN: Yes
Website / /
Street Address: City/State: Zip Code:
Cell Phone Number: Home Phone Number: Employer: Work Phone Number:
How did you hear about our office?: Preferred Pharmacy (Name and location): Pharmacy Phone Number:
Name of Primary Care Physician:
PCP Phone number:
Name of Orthopedic Surgeon:
IN CASE OF EMERGENCY
Name of local friend or relative: Relationship to patient: Phone number:
(Please give insurance card to the receptionist) Primary Insurance Company Name:
6XEVFULEHU¶V1DPH Relationship to patient: Date of Birth: / /
Group Number: Policy Number: Co-payment: $
Name of secondary insurance (if applicable):
6XEVFULEHU¶V1DPH Relationship to patient: Birth Date: / /
Group Number: Policy Number: Co-payment: $
Name of person responsible for bill: Relationship to patient: Phone number: $GGUHVVRISHUVRQUHVSRQVLEOHIRUELOOLIGLIIHUHQWWKDQWKHSDWLHQW¶V
The above information is true to the best of my knowledge. I authorize Rheumatology Associates of North Texas, PA to apply for benefits on my behalf for covered services rendered by Rheumatology Associates of North Texas, PA. I request my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Rheumatology Associates of North Texas, PA or the insurance company to release any information required to process my claims.
3DWLHQW¶V1DPHBBBBBBBBBBBBBBBBBBBBBB________________ Date of Birth: _______________________________ - 1 -
Rheumatology Associates of North Texas, PA
4461 Coit Road, Suite 402
Phone (214) 297-0099
Fax (214) 297-1102
Please complete the entire patient packet before arriving for your appointment. If the packet
is not completed, we may have to reschedule your appointment. If you have any lab results
or imaging results from another physician, bring them with you to your appointment or
make sure your physician forwards the results to our office before your appointment.CURRENT MEDICATION LIST
PRESCRIPTIONS, OVER THE COUNTER MEDICATIONS, VITAMINS
Medication Dosage Frequency Reason prescribed
Please state the year of your last:
Flu Vaccine ______ Pneumonia Vaccine ______ Tetanus Vaccine ______ Shingles Vaccine _______ Hepatitis B Vaccine _______
Medication Reaction Other Allergies Reaction
YOUR PAST MEDICAL HISTORY: Have YOU ever been diagnosed with any of the following diseases?
Cancer/Leukemia/Lymphoma Heart Disease Diabetes High blood pressure High Cholesterol Stroke Emphysema/COPD/Asthma Kidney disease Thyroid disease Jaundice/Hepatitis Tuberculosis Pneumonia HIV/ AIDS Headaches Depression Nervous Breakdown Glaucoma Anemia Rheumatic Fever Alcoholism /XSXVRU³6/(´ Childhood arthritis Epilepsy Goiter Rheumatoid Arthritis Psoriasis Migraines Ankylosing Spondylitis Colitis Unspecified Arthritis Osteoporosis Iritis/Uveitis Osteoarthritis Chronic fatigue syndrome Sarcoidosis Gout Fibromyalgia
3DWLHQW¶V1DPHBBBBBBBBBBBBBBBBBBBBBB________________ Date of Birth: _______________________________ - 2 -
Previous Operations/ Surgical History
Type Year Reason
1. 2. 3. 4. 5. 6.
Any previous fractures or dislocations? No Yes Describe: ______________________________________________________
Please state the year of your last:
Bone Densitometry: _______ Mammogram:_______ Eye exam:_______ Chest x±ray:_______ Tuberculosis Test:_______
FAMILY HISTORY (Blood relatives ONLY):
Has your mother, father, sibling, child, grandparent, aunt, or uncle had any of the following? (List their relationship to you
next to the condition. Be sure to mention if the relative LVRQ\RXUPRWKHURUIDWKHU¶VVLGHRIWKHIDPLO\
Condition Relationship Condition Relationship
Unspecified arthritis Chronic fatigue
/XSXVRU³6/(´ Cancer (list type)
Rheumatoid Arthritis Colitis
Ankylosing Spondylitis Heart Disease
Diabetes (type) High blood pressure
Bleeding tendency Alcoholism
Epilepsy Rheumatic fever
Marital Status: Never Married Married Partner Separated Divorced Widowed
Education (circle highest level attended):
Grade School 7 8 9 10 11 12 College 1 2 3 4 Graduate School _____________________________
Occupation ________________________________________ Number of hours worked/average per week ___________________
Do you exercise regularly? ެNo ެYes Frequency________________ Please describe _______________________
Do you smoke? NeverCurrentPrevious Amount per day_________ Age you started:_______ Age you quit:_________
Do you drink alcohol? No Yes Number per week_____ Has anyone ever told you to cut down on your drinking? No Yes Do you drink caffeine? No Yes Cups/glasses per day?______________
Chewing tobacco? Never Current Previous Amount per day______ Age you started :______ Age you quit:_______
3DWLHQW¶V1DPHBBBBBBBBBBBBBBBBBBBBBB________________ Date of Birth: _______________________________ - 3 -
HISTORY OF PRESENT ILLNESS
Describe briefly your present symptoms:
Date symptoms began (approximate):
Previous treatment for this problem (include physical therapy, surgery and injections; medications to be listed later)
Please list the names of other practitioners you have seen for this problem:
REVIEW OF SYSTEMS
As you review the following list, please check any of those problems which have significantly affected you.
How long?______Minutes ______Hours Joint pain
List joints affected in the last 6 mos.
Muscle weakness Muscle tenderness Muscle spasm Back pain Constitutional Exercise intolerance Fever or chills Night sweats Recent weight loss
Amount ___________________ Recent weight gain
Double or blurred vision Redness Dryness Irritation Ears±NoseMouth/Throat Difficulty hearing Ear pain Ringing in ears Frequent nosebleeds Sinus pain Dryness of mouth Difficulty swallowing Sores in mouth Teeth problems Bleeding gums Frequent sore throats Snoring
Arm pain on exertion Light-headed upon standing Shortness of breath when laying Shortness of breath when walking Swollen legs or feet
Color changes of hands in the cold Palpitations
Sudden changes in heart beat Heart murmurs
Shortness of breath Cough
Difficulty breathing at night Coughing of blood Wheezing (asthma) Gastrointestinal Nausea / Vomiting Abdominal pain Heartburn Diarrhea Constipation Vomiting blood Abnormal appetite Blood in stools Black/tarry stools Genitourinary Difficulty urinating Blood in urine
Pain or burning on urination Cloudy urine
Inability to empty bladder Loss of bladder control Increased urine frequency Genital rash/ulcers
Date of last period? / / /
Thickness of skin Tightness of skin Rash
Sun sensitive (sun allergy) Abnormal mole Jaundice Nail pits Neurological System Loss of consciousness Weakness
Numbness or tingling in hands Numbness or tingling in feet Headaches
Dizziness Fainting Seizures
Sleep disturbances/Restless sleep Feeling unsafe in a relationship Anxiety Panic attacks Depression Alcohol abuse Endocrine Excessive thirst Fatigue Hair loss
Increased hair growth Cold Intolerance
Blood clot in artery, vein, or lung Bleeding tendency Swollen glands Anemia Transfusion/when ______________ Allergic/Immunologic Frequent sneezing
Increased susceptibility to infection Runny nose
Sinus pressure Hives
Rheumatology Associates of North Texas, PA
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996, revised in 2013, requires us as your health care provider to maintain the privacy of your protected health information, to provide you with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We are required to maintain these records of your health care and are dedicated to maintaining confidentiality.
The Act also allows us to use your information for treatment, payment, and certain health operations unless otherwise prohibited by law and without your authorization.
• Treatment: We may disclose your protected health information to you and to our staff or to other health care providers in order to get you the care you need. This includes information that may go to the pharmacy to get your prescription filled, to a diagnostic center to assist with your diagnosis, or to the hospital should you need to be admitted. If necessary to ensure that you get this care, we may also discuss the minimum necessary with friends or family members involved in your care unless you request otherwise.
• Payment: We may send information to you or to your health plan in order to receive payment for the service or item we delivered. We may discuss the minimum necessary with friends or family members involved in your payment unless you request otherwise.
• Health operations: We are allowed to use or disclose your protected health information to train new health care workers, to evaluate the health care delivered, to improve our business development, or for other internal needs.
• We are required to disclose information as required by law, such as public health regulations, health care oversight activities, certain law suits and law enforcement.
Certain ways that your protected health information could be used or disclosed require an authorization from you: use or disclosure for marketing purposes and disclosures or uses that constitute a sale of protected health information. We cannot disclose your protected health information to your employer or to your school without your authorization unless required by law. Other uses and disclosures not described in this notice will be made only with your written authorization, which you may revoke going forward in writing.
You have several rights concerning your protected health information. When you wish to use one of these rights, please inform our office so that we may give you the correct form for documenting your request.
copy. We may charge you our cost for making and providing the copy. If your request is denied, you may request a review of this denial by a licensed health care provider.
You have the right to request restrictions on how your protected health information is used for treatment, payment, and health operations. For example, you may request that a certain friend or family member not have access to this information. We are not required to agree to this request, but if we agree to your request, we are obligated to fulfill the request, except in an emergency where this restriction might interfere with your care. We may terminate these restrictions if necessary to fulfill treatment and payment.
We are required to grant your request for restriction if the requested restriction applies only to information that would be submitted to a health plan for payment for a health care service or item or for health operations, if you have paid for the item or service in full out of pocket, and if the restriction is not otherwise forbidden by law. For example, we are required to submit information to federal health plans and managed care organizations even if you request a restriction. We must have your restriction documented prior to initiating the service. Some exceptions may apply, so ask for a form to request the restriction and to get additional information. We are not required to inform other covered entities of this request, but we are not allowed to use or disclose information that has been restricted to business associates that may disclose the information to the health plan.
You have the right to request confidential communications. For example, you may prefer that we call your cell phone number rather than your home phone. These requests must be in writing and may be revoked in writing and must give us an effective means of communication for us to comply. If the alternate means of communications incurs additional cost, that cost will be passed on to you.
Your medical records are legal documents that provide crucial information regarding your care. You have the right to request an amendment to your medical records, but you must make this request in writing and understand that we are not required to grant this request.
You have the right to an accounting of disclosures. This will tell you how we have used or disclosed your protected health information.
You have the right to receive a copy of this notice, either electronic or paper. The copy may be provided electronically with your permission.
If you have any questions about our privacy practices, please contact our Privacy Officer at the number below.
You have the right to file a complaint with us or with the Office for Civil Rights. We will not discriminate or retaliate in any way for this action. To file a complaint, please contact the applicable party:
Privacy Officer Phone number: 214-297-0099
Office for Civil Rights http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html