New Patient Forms

Patient Information

Patient Name: *

SS#/HIC/Patient ID#: *

Mailing Address (Please include apt or suite #): *

City: *

State: *

Zip: *

Home Phone:

Work Phone:

Cell Phone:

Sex: *MaleFemale

Date of Birth: *

Occupation:

Patient Employer:

Employer Address:

Employer Phone:

Spouse’s Name:

Date of Birth:

SS#:

Spouse’s Employer:

Pharmacy Name: *

Pharmacy Phone: *

Pharmacy Fax:

Insurance

Date *

Subscriber’s Name: *

Date of Birth: *

SS#: *

Relationship to Patient: *

Insurance Company: *

Policy Number: *

Is patient covered by secondary insurance? *YesNo

Subscriber’s Name:

Date of Birth:

SS#:

Relationship to Patient:

Insurance Company:

Policy Number:

Is patient covered by tertiary insurance? *YesNo

Subscriber’s Name:

Date of Birth:

SS#:

Relationship to Patient:

Insurance Company:

Policy Number:

Assignment and Release

I certify that I, and or my dependant(s), have insurance coverage with

and assign directly to Dr.

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named doctor may use my healthcare information and may disclose such information to the above named Insurance Company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for the related services. This consent will end when my current treatment plan is completed.

*

(Patient’s Signature)

Date *

Patient Privacy Release

Written authorization is required from the patient giving permission for North Georgia Kidney Specialists physicians and staff to discuss any matters related to the patient with family members or guardians.

I,

authorize Dr.

and staff to release, discuss and confer with the following people in any situation such as procedures, conferences, emergencies, test results and decisions that are to be made while I am a patient of North Georgia Kidney Specialists.

*

(Patient Signature)

Date *

Medical Records Release

Written authorization is required from the patient giving permission for North Georgia Kidney Specialists physicians and staff to obtain medical records from other physicians the patient has seen.
TO:

I hereby authorize you to furnish a copy of my medical records to North Georgia Kidney Specialists located at 880 Canton Road, Suite 400, Marietta, GA 30060. I release you from all legal responsibility or liability that may arise from this authorization.

Patient’s Name: *

Date of Birth: *

Social Security Number: *

*

(Patient Signature)

Date *

North Georgia Kidney Specialist

NOTICE OF PRIVACY PRACTICES

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

*This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your individually identifiable health information.

PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important information:

How we may use and disclose your IIHI
Your privacy rights in your IIHI
Our obligations concerning the use and disclosure of your IIHI

The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Dia Koss
880 Canton Road Suite 400
Marietta, GA 30060
770-528-9788

C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS

The following categories describe the different ways in which we may use and disclose your IIHI.

1. Treatment. Our practice may use your IIHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your IIHI to other health care providers for purposes related to your treatment.

2. Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your IIHI to bill you directly for services and items. We may disclose your IIHI to other health care providers and entities to assist in their billing and collection efforts.

3. Health Care Operations. Our practice may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your IIHI to other health care providers and entities to assist in their health care operations.

4. Appointment Reminders. Our practice may use and disclose your IIHI to contact you and remind you of an appointment.

5. Release of Information to Family/Friends. Our practice may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.

6. Disclosures Required By Law. Our practice will use and disclose your IIHI when we are required to do so by federal, state or local law.

D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN SPECIAL CIRCUMSTANCES

The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

1. Public Health Risks. Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the purpose of:

- maintaining vital records, such as births and deaths
- reporting child abuse or neglect
- preventing or controlling disease, injury or disability
- notifying a person regarding potential exposure to a communicable disease
- notifying a person regarding a potential risk for spreading or contracting a disease or condition
- reporting reactions to drugs or problems with products or devices
- notifying individuals if a product or device they may be using has been recalled
- notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
- notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance

2. Health Oversight Activities. Our practice may disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:

- - Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
  - Concerning a death we believe has resulted from criminal conduct
  - Regarding criminal conduct at our offices
  - In response to a warrant, summons, court order, subpoena or similar legal process
  - To identify/locate a suspect, material witness, fugitive or missing person
  - In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

5. Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

6. Organ and Tissue Donation. Our practice may release your IIHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.

7. Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

8. Military. Our practice may disclose your IIHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

9. National Security. Our practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

10. Inmates. Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

11. Workers’ Compensation. Our practice may release your IIHI for workers’ compensation and similar programs.

E. YOUR RIGHTS REGARDING YOUR IIHI

You have the following rights regarding the IIHI that we maintain about you:

1. Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Dia Koss 770-528-9788 specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your IIHI, you must make your request in writing to Dia Koss 770-528-9788. Your request must describe in a clear and concise fashion:

(a) the information you wish restricted;
(b) whether you are requesting to limit our practice’s use, disclosure or both; and
(c) to whom you want the limits to apply.

3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Dia Koss 770-528-9788 in order to inspect and/or obtain a copy of your IIHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Dia Koss 770-528-9788. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your IIHI for non-treatment, non-payment or non-operations purposes. Use of your IIHI as part of the routine patient care in our practice is not required to be documented (For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim). In order to obtain an accounting of disclosures, you must submit your request in writing to Dia Koss 770 528-9788. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Dia Koss 770-528-9788.

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Dia Koss 770-528-9788. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note, we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact Dia Koss 770-528-9788.

Notice Of Privacy Practices

Written acknowledgement of the North Georgia Kidney Specialists’ Privacy Policy is required by the Privacy Regulations created as a result of the HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996. (HIPAA)

I,

have received a copy of North Georgia Kidney Specialists’ Privacy Practices. If you have any questions or concerns please do not hesitate to contact us at 770-528-9788.

*

(Signature of Patient)

Date *

Cancellation Policy

Date *

I understand that North Georgia Kidney Specialists has a $25 No-Show Fee for patients who do not give at least 24 hours notice prior to cancellation of their appointment. Further, I acknowledge that should I assess a No-Show Fee, this fee must be paid before a future appointment will be scheduled.

*

(Signature of Patient)

Date *

Name *

Date of Service: *

Medical History Form

Please mark any changes in your personal or family medical history.

Family Medical History

Social History

TobaccoCurrentPastN/A

How Much?

How Long?

AlcoholCurrentPastN/A

How Much?

How Long?

Drug UseCurrentPastN/A

How Much?

How Long?

Medication History

Current Medications / Dose (mg,mcg,units) / Times a Day / Ordering Physician

Upload file

No file chosen

Allergies

List your allergies to medications or other substances:

Upload file

No file chosen

Name *

Date of Service: *

Medical History Form

The information you provide to your doctor is confidential and cannot be released without your authorization.

Medical Problems

Year of last normal BP:

Type12

Other disorder

Year of onset:

# Pregnancies

Complications:

EyeKidneyNerve

# Deliveries

Hospitalizations

Please list all of your previous visits to the hospital, include ER visits and surgeries.

Reason for Hospitalization / Date

Name *

Date of Service: *

Interim Health Report

Please mark any changes in your personal or family medical history.

Family, Past, and Social History

Hospitalizations/Surgery:

If you have diabetes: When was your last eye appointment?

When was your last foot exam?

If you are 50 years old or older when was your last colonoscopy?

New Medical Problems or Tests:

New Medications:

Deaths or illnesses in your family:

Last menstrual period or change in menses:

How much exercise do you get?

If you are getting iron infusions when was your last infusion?

Review of Systems

Have you experienced any of the following symptoms (problems) (Pick Yes or No):

Constitutional

Skin

Fever/Chills *YesNo

Rash *YesNo

Weight Loss *YesNo

Itching *YesNo

Eyes

Joints & Muscles

Visual Changes *YesNo

Joint, back, neck Pain *YesNo

Pain *YesNo

Muscle Pain *YesNo

Allergic/Immunologic

Hematological

Hay Fever *YesNo

Bruising/Bleeding *YesNo

Drug Allergies *YesNo

Transfusions *YesNo

Endocrine

Ear, Nose & Throat

Heat/Cold Intolerance *YesNo

Ear/Throat Pain *YesNo

Tired or Sluggish *YesNo

Difficulty Hearing *YesNo

Heart & Blood Vessels

Sinus Trouble *YesNo

Chest Pain *YesNo

Bladder and Urination

Heart Skip a Beat *YesNo

Difficulty urinating *YesNo

Swelling of the Legs *YesNo

Incontinence *YesNo

Neurological

Urinary frequency *YesNo

Dizziness *YesNo

Abnormal vaginal bleeding *YesNo

Numbness/Tingling *YesNo

Respiratory

Psychological

Wheezing *YesNo

Do you feel hopeless *YesNo

Cough *YesNo

Do you feel depressed *YesNo

Shortness of breath *YesNo

Gastrointestinal

Loud snoring *YesNo

Belly Pain *YesNo

Diarrhea/Constipation *YesNo

Nausea or Vomiting *YesNo