Attach to Your Paperwork - South MS Surgical …...South Mississippi Surgical Weight Loss Center 1124 Oakleigh Road Ocean Springs, MS 39564 228.872.7277 800.537.8809 Fax: 228.818.3978

South Mississippi Surgical Weight Loss Center 1124 Oakleigh Road ● Ocean Springs, MS 39564

228.872.7277 ● 800.537.8809 ● Fax: 228.818.3978

www.smsurgicalweightloss.com

Attach to Your Paperwork In order to process your paperwork and verify your insurance benefits, we request that you please include copy of:

• the front of your insurance card • the back of your insurance card • your driver’s license

Return Your Paperwork You can submit this paperwork during an office visit or send it via:

• Fax: (228) 818-3978 • Email: [email protected]

Prepare for Your Visit Each time you come to our office for an appointment you will have to remove your socks and shoes for our Tanita scale to measure your body mass index (BMI). You may want to wear shoes and socks that are easy on – easy off.

License Front & Back of Insurance Card

mailto:[email protected]

MEDICAL HISTORY FORMMEDICAL HISTORY FORMMEDICAL HISTORY FORMMEDICAL HISTORY FORM

Patient: Date of Birth:

Revised: 04/7/2016 LR Page 1 of 14

Patient InformationPatient InformationPatient InformationPatient Information

Referring Doctor: Language Choice:

Pharmacy: Pharm City/State:

Last Name: First Name: MI:

Street Address: City: State: Zip:

Mailing Address: City: State: Zip:

Home Phone #: Work #: Cell #:

Date of Birth: SSN: Gender:

Marital Status: Spouse’s Name:

Employer

Emergency ContactEmergency ContactEmergency ContactEmergency Contact That does not live with you.

Relation Phone #:

Do we have your permission to:Do we have your permission to:Do we have your permission to:Do we have your permission to: Can we discuss medical condition with Can we discuss medical condition with Can we discuss medical condition with Can we discuss medical condition with

household or family members? household or family members? household or family members? household or family members?

Yes No

Leave a message on your cell phone? Yes No N/A If yes, please list.

Leave a message on your home answering machine? Yes No N/A Name Relation

Leave a message at your place of employment? Yes No N/A

Can we email about appointments or medical condition? Yes No N/A

E-mail Address:

Guardian Information for Minor PatientsGuardian Information for Minor PatientsGuardian Information for Minor PatientsGuardian Information for Minor Patients

Relationship: Last Name: First Name: MI:

Birth Date: SSN: Home #: Work #:

Address: City: State: Zip:

Insurance InformationInsurance InformationInsurance InformationInsurance Information MEDICARE #:

Provide insurance cards and a photo ID to the receptionist so that copies can be made. MEDICAID #:

PRIMARY INSURANCE SECONDARY INSURANCE

Insured Name: Insured Name:

Relationship to Patient: Relationship to Patient:

Date of Birth: Date of Birth:

Insurance Company: Insurance Company:

SSN: SSN:

Group #: Group #:

Policy #: Policy #:

Employer Name: Employer Name:

Employer Address: Employer Address:

Date Patient Signature

MEDICAL HISTORY FORM



Patient Information and Demographics

Date: Race: Age: Height:

Current Weight: Weight Loss Goal:

Surgery/Program you plan to have or participate in:

Adjustable Gastric Banding Sleeve Gastrectomy

Roux-en-Y Bypass Non-Surgical Weight Management (OPTIFAST®)

How did you hear about our Program?

Occupation:

Education:

Grade School High School Some College College Degree Post Grad

Are you currently under the care of a Family Physician?

Yes Are you under the care of a Mental Health Professional?

Yes

No No

Name: Name:

Address: Address:

City/State: City/State:

Phone: Fax: Phone: Fax:

May we contact him or her? Yes No May we contact him or her? Yes No




Medical Weight Loss History

Check any of the following programs you have tried in an attempt to lose weight:

Yes No Diet Pills by MD

Yes No Diet Shots by MD

Yes No Supervised Calorie Counting by a Healthcare Professional

Yes No OPTIFAST®

Yes No Weight Watchers®

Yes No NutriSystem®

Yes No Atkins Diet®

Yes No Sugar Busters®

Yes No Low Fat

Yes No Mayo Clinic

Yes No Health Management Resources

Yes No TOPS®

Yes No Overeaters Anonymous®

Yes No Grapefruit Diet

Yes No Richard Simmons

Yes No Calorie Counting on Own

Yes No Slim Fast®

Yes No Other:




Past Medical History/Co‐Morbid Conditions: Please check yes or no if you have or have had any of the following medical problems Medical or Co‐Morbid Condition Medical or Co‐Morbid Condition

Yes No Congestive Heart Failure Yes No Renal Insufficiency (Chronic Kidney Disease)

Yes No Abnormal EKG Yes No GERD or Reflux

Yes No Stroke Yes No Liver Disease (Jaundice)

Yes No Peripheral Vascular Disease Yes No Crohn’s Disease

Yes No Lower Extremity Swelling Yes No Do You Require a Wheelchair or Scooter to Get Around?

Yes No Deep Vein Thrombosis (DVT) or Pulmonary Embolism (Blood Clot)

Yes No Barrett’s Esophagus

Yes No Joint Pain Yes No Back Pain, hip or leg pain

Yes No Degenerative Joint Disease Yes No Hypothyroidism

Yes No Lupus or Any Autoimmune Disorder Yes No Irregular Period

Yes No Polycystic Ovarian Syndrome (PCOS) Yes No Stomach Ulcers

Yes No Abdominal Hernia Yes No Currently on dialysis?

Yes No Heart Attack Yes No Currently on a transplant list?

Yes No Chronic obstructive pulmonary disease (COPD) Yes No OTHER:

Yes No Do you currently or have ever been diagnosed with a mental illness? If yes, indicate the diagnosis:

Medical or Co‐Morbid Condition If yes, list medication:

Yes No High Blood Pressure

Yes No Diabetes, Pre‐Diabetes, or Gestational Diabetes

Yes No High Cholesterol:

Yes No Sleep Apnea: Do you or should you be using a BiPAP or CPAP machine?

Yes No Is there any reason you would NOT accept or consent to a blood transfusion or blood products? (For life saving




Medications Do you take a blood thinner? Yes No IF YES: Which Medication: Reason:

How long have

you taken them?

Do you take steroids? Yes No

IF YES: Which Medication: Reason:

How long have

you taken them?

Have you ever been told you need antibiotics to protect your heart before you have surgery? Yes No

IF YES: Which Medication: Reason: Other Prescriptions, Vitamins/Minerals, Herbal Supplements, or Over-the-Counter Drugs Currently Taken

MEDICATION DOSE HOW MANY TIMES A DAY REASON




Allergies – List Drug, Food, or Material Allergies

Past Surgical History

Have you ever had any previous weight loss procedure? Yes No

IF YES: Surgery Type: Year:

Surgeon:

Lowest Pre-Surgery Weight: Highest Pre-Surgery Weight:

How long did you maintain your weight loss?

Have you ever had a heart cath? Yes No

IF YES: Year: Reason:

Did it require a stent? Yes No

Have you ever had a colonoscopy? Yes No


Have you ever had an EGD (Where a camera looks into your stomach)? Yes No


Have you ever had a mammogram? Yes No IF YES: Year: Surgeries - List any other surgeries.

Surgery Date




Nutritional, Dieting, and Exercise History How long have you been overweight?

At what age were you first overweight by 10 pounds or more?

Is this the first time you have been evaluated for weight loss surgery? Yes No

What is your worst diet habit?

In the past, what has been your best weight loss method?

My all-time highest weight was pounds at years old.

My highest weight after age 21 was pounds at years old.

Social History Do You Smoke? Yes No Frequency of Use

If you once smoked, when did you quit? Rarely Occasionally Frequently

Do you drink alcohol? Yes No Frequency of Use

If you once drank, when did you quit? Rarely Occasionally Frequently

Have you or are you addicted to prescription or illegal drugs? Yes No

If so, what? Frequency of Use

How long? Rarely Occasionally Frequently

Family History Please check if appropriate:

Obesity Mother Father Sister Brother

Diabetes Mother Father Sister Brother

Hypertension Mother Father Sister Brother

Cardiac Disease Mother Father Sister Brother

Sudden Death Mother Father Sister Brother

Cancer Mother Father Sister Brother If you have a family history of cancer, please specify what type:




Review of Systems

Indicate which of the following symptoms you have experienced in the past 6 months.

Yes No Abdominal Hernia Yes No History of Pneumonia

Yes No Abdominal Pain Yes No History of problems w/ anesthesia

Yes No Abnormal Chest X-ray Yes No Indigestion

Yes No Abnormal Range of Motion Yes No Jaundice

Yes No Anemia Yes No Joint Stiffness

Yes No Arthritis Yes No Kidney Stones

Yes No Asthma Yes No Murmur

Yes No Blood Transfusion Yes No Muscle Weakness

Yes No Bronchitis Yes No Nausea

Yes No Chest Pain Yes No Night Sweats

Yes No Constipation Yes No Numbness

Yes No Diarrhea Yes No Occasional Difficulty Breathing at Night

Yes No Difficulty Swallowing Yes No Rapid Heartbeat

Yes No Difficulty with snoring Yes No Seizures

Yes No Easy Bruising Yes No Shortness of Breath

Yes No Emphysema Yes No Shortness of Breath Upon Exertion Exerting Oneself

Yes No Excessive Sweating Yes No Sores or Ulcers of Skin

Yes No Excessive Thirst Yes No Swelling in Extremities

Yes No Fatigue Yes No Thyroid Problems (hyper or Hypo)

Yes No Heart Devices (Defibrillator, etc.) Yes No Tingling

Yes No Heart Valve Damage Yes No Vomiting

Yes No Heat/Cold Intolerance Yes No Weakness

Yes No Hepatitis Yes No Wheezing




AUTHORIZATION TO RELEASE COPIES

OF MEDICAL RECORDS FROM SOUTH MISSISSIPPI SURGEONS

Date:

Patient Name:

Patient Address:

City: State: Zip:

Date of Birth: Social Security #:

I, ________________________________ , hereby authorize: SOUTH MS SURGICAL WEIGHT LOSS CENTER TO RELEASE COPIES OF MEDICAL RECORDS ON THE ABOVE INDICATED PATIENT.

______ (INITIALS) Protected information: By signing here I understand that medical records released may contain information related to HIV status, AIDS, sexually transmitted diseases, mental health, drug and alcohol abuse. I understand that such information is protected by federal law and will not be shared with anyone unless authorized separately.

Patient Signature




AUTHORIZATION TO RELEASE COPIES OF MEDICAL RECORDS TO

SOUTH MISSISSIPPI SURGEONS

Date:

Patient Name:

Patient Address:

City: State: Zip:


I, ________________________________ , hereby authorize _________________________________________ to release copies of medical records on the above indicated patient to SOUTH MS SURGICAL WEIGHT LOSS CENTER.

______ (INITIALS) Protected information: By signing here I understand that medical records released may contain information related to HIV status, AIDS, sexually transmitted diseases, mental health, drug and alcohol abuse. I understand that such information is protected by federal law and will not be shared with anyone unless authorized separately.

Patient Signature




Consent for Treatment This consent is not to be used or considered an informed consent for operation or surgical procedures. This is to certify that the undersigned authorizes the examination and/or treatment as may be necessary or advisable completed within the office of South Mississippi Surgical Weight Loss Center, LLC (SMSWLC). 1. I consent to my photograph to be taken by SMSWLC for identification and documentation purposes.

2. The undersigned as the patient or his/her authorized legal representative do hereby authorize SMSWLC to

release to my insurance company or other appropriate agencies, information necessary to validate this claim for billing purposes.

3. SMSWLC is also hereby authorized to release to any other physicians or medical entity information as needed for treatment, care of the insured.

4. I hereby authorize any medical and/or health insurance company to pay the proceeds of any benefits due me directly to SMSWLC. A copy of this form can be considered as an original for insurance purposes. I acknowledge and understand that I am responsible for all of the charges for all of the services rendered to me or the indicated person for whom I am financially responsible. Although I have requested the doctors to bill my insurance company on my behalf, I clearly understand that it is still my responsibility to make sure the bill is paid in a reasonable time. If for any reason any portion of my bill is not paid by my insurance company, I further agree to make arrangements for prompt payment of the bill.

5. I have read this agreement and understand the contents.

Patient Name (Print) Date Patient Name (Signature)

Responsible Party Name (Print) Relationship Responsible Party Name (Signature)

6. Statement to Permit Payment of Medicare/Medicaid Benefits to SOUTH MISSISSIPPI SURGEONS, P.A.

and/or

Medicare # Medicaid # Beneficiary

I request that payment of authorized MEDICARE/MEDICAID benefits be made on my behalf to SMSWLC for services furnished me by physicians associated with SMSWLC. I authorize SMSWLC to release Health Care Financing Administration or Medicaid and its agents any information needed to determine these benefits or the benefits payable for related services.

Patient/Responsible Party Signature




Financial Policy

Thank you for choosing South Mississippi Surgical Weight Loss Center, LLC (SMSWLC) as your healthcare provider. We are committed to providing you the best possible service at the lowest possible price. Following is a statement of our financial policy which we require you to read and sign prior to treatment. SMSWLC accepts payment for professional services in the form of cash, check, credit card or patient financing. All patients will be required to establish a financial arrangement when services are rendered. In addition, we accept insurance from major insurance companies. PLEASE BE AWARE THAT FEW INSURANCE COMPANIES ATTEMPT TO COVER ALL MEDICAL COSTS. EACH PATIENT IS REQUIRED TO MAKE A DEPOSIT PRIOR TO SURGERY. Your insurance coverage is a contract between you and your insurance carrier. We will assist you in maximizing your insurance benefits and in obtaining necessary pre-certifications. As a courtesy we will review your insurance coverage, estimate your insurance payment, review your insurance form and file your claim with the carrier. To avoid any misunderstanding, we will require you to assign all insurance benefits for professional services directly to our office. If you request your insurance company to pay you directly, we will require full payment from you at the time of service. You will be notified when the insurance carrier remits payment to our practice. We will apply this payment to your account and refund any credit balance within 30 days. If an insurance problem occurs you will be asked to assist us in contacting your insurance carrier. We feel it is necessary to work together to resolve any insurance problem. YOU WILL BE RESPONSIBLE FOR ANY PORTION OF YOUR BILL WHICH IS DENIED OR NOT PAID BY YOUR INSURANCE CARRIER. If this bill is not paid within the ninety (90) day period from demand or billing, SMSWLC may add a collection fee of up to 30% or $10.00 whichever is higher. If the account is turned over to a collection agency or attorney, a 30% fee will be added to the account. Our practice firmly believes that a good doctor/patient relationship is based upon understanding and good communication. Our staff has been instructed to make every effort to clarify any misunderstandings you have concerning your balance. If you have any questions concerning our financial policy or need any assistance, please contact our practice immediately at 769-2069. I have read, understand and agree to the financial policy.

Signature of Patient or Responsible Party Date




Authorization to Obtain Medication History

Patient Name:

Patient Address:

City: State: Zip:


By signing below, I hereby authorize South Mississippi Surgical Weight Loss Center, LLC to obtain Medication

History related to the patient above, from Community Pharmacies and/or Pharmacy Benefit Managers for the

purpose of Continued Treatment.

Authorization Date Print Name of Patient/Legal Representative or

Parent/Legal Guardian

Signature of Patient/Legal Representative or

Parent/Legal Guardian

I understand that this authorization is revocable upon written notice to the office where the original authorization

is retained, except to the extent that action has already been taken on this authorization. South Mississippi

Surgical Weight Loss Center, LLC may not condition the provision of treatment, payment, enrollment in the health

plan, or eligibility for benefits on the provision of this authorization.




Marketing Consent and Disclosure I understand that by providing this marketing consent to South Mississippi Surgical Weight Loss Center (SMSWLC) and/or its delegates, I am allowing these parties to use my images, name, related weight loss information, and related co-morbid condition information to promote SMSWLC. I understand that by providing my consent, SMSWLC and/or it’s delegates may post my name, type of surgery, weight loss statistics, physician who performed my surgery, and images on platforms, including without limitation, Facebook, Twitter, Pinterest, YouTube, and/or Google+, on its internet site, and may use such information in print or other published marketing materials promoting SMSWLC. I am aware of the public disclosure of my surgery by providing my permission hereunder to use my information and images. I also understand the following: SMSWLC reserves the right to monitor, prohibit, restrict, block, suspend, terminate, delete, or discontinue your content to our marketing platforms at any time, without notice, and for any reason and in its sole discretion. SMSWLC and/or its affiliates cannot be held liable for comments made with regard to my images or information. Consent to use my information and images is not consent to post or otherwise disclose any other personal medical information about me. This consent will expire upon the discontinuance by SMSWLC of any marketing efforts through any marketing platforms, the internet, or printed marketing materials. I understand that I may revoke this consent in writing at any time sending such written revocation to SMSWLC at the address set forth above and to the attention of Warren N. Collmer. A reasonable time lag may exist while my revocation is processed and before the information and images are removed from applicable marketing platforms or internet sites and that my information and images cannot be removed from any previously published materials such as marketing brochures already printed and in circulation. Additionally, SMSWLC cannot be responsible for copied, shared and distributed content through the channels of social networks and the internet. Accordingly, due to the risk of redisclosure by others of my information once posted to any marketing or any internet site, such information will no longer be protected by 45 CFR § 164.508 under HIPAA. It is my responsibility to contact site owners wherein images have been compromised and/or reposted to request removal of my images. SMSWLC may not condition any treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization. I have read, understand and agree to this marketing consent and disclosure.

Signature of Patient or Responsible Party Date

Attach to Your Paperwork - South MS Surgical …...South Mississippi Surgical Weight Loss Center 1124 Oakleigh Road Ocean Springs, MS 39564 228.872.7277 800.537.8809 Fax: 228.818.3978

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