Today’s Date: Name: Date of Birth: Seen at the request of:
Dr./Nurse Practitioner: Clinic: Preferred Language: Race: q American Indian/Alaskan Native q Asian
Ethnicity: q Hispanic or Latino q Native Hawaiian/Other Pacific Islander q White
q Black/African American q Hispanic
q Not Hispanic or Latino Chief Complaint / History of Illness:
What is the reason for today’s visit? How long have you had this problem? How severe is this problem? What makes it better? What makes it worse? What other symptoms are you having? Medications: (list all your current medications and the dose)
Allergies: (List medications/foods and what happens) Allergies to tape, iodine or latex: List the dates for the following radiology tests:
Head X ray: Allergy Testing:
When? Thyroid X ray: Clinic? CT/MRI Scans: Immunotherapy? Y
Upper GI/ Barium Swallow N
Social History:
Occupation: Have you worked in a noisy environment? If so, what kind? Exposure to loud noises? Other: Do you smoke? Do you chew? Are you thinking about quitting? How much? When did you quit? How much alcohol do you drink each day? List any street drug use: Do you have an advanced directive? centMH 4/12
BEND • 2450 NE Mary Rose Place, Suite 120 • 541.382.3100 | REDMOND • 1523 NW Canal Boulevard, Suite 101 • 541.548.4002
www.coent.com
Past Medical History: High blood Pressure Kidney Disease Diabetes Heart Disease/Angina Asthma/Emphysema (please circle)
Stroke/Mini stroke Cancer (list type & date below) Yes Right
Past Surgical History: Surgery for cancer Mastectomy Skin cancer surgery Sinus Surgery Tonsillectomy Review of Systems: Ringing R Ear Ringing L Ear Dizziness Pain in R Ear Pain in L Ear Drainage from R Drainage from L Ear Hearing loss R Ear
Hearing loss L Ear Nasal congestion Nasal drainage Facial pain External facial deformity Nasal bleeding (please circle) No Left
Yes
Thyroid Disease Hepatitis/liver disease Tuberculosis/TB HIV/AIDS Rheumatic Fever Arthritis Others: Yes
_____
No No
Yes
No
Heart surgery Lung surgery
Colon Removal Neck/spine
Others: Hoarseness Throat Clearing
Swallowing pain
Discomfort in throat
Something in Throat
Ear Cough
Heartburn/Sour taste
White balls on tonsils
Large tonsils
Right
Itchy nose/ears/eyes
Runny/watery eyes
Sneezing fits
Runny nose
Scratchy throat
Loud snoring
Stop breathing while asleep Excessive daytime sleepiness Skin cancers
Blood in stool
Vomiting Nausea Recent weight loss Fevers/Chills Night sweats Fatigue
Neck/back pain
Loss of sensation
Paralysis of arm/leg
Loss of speech
Facial droop
Chest pain/tightness Poor circulation Irregular heartbeat Shortness of breath
Wheezing
Others: Family History Hearing loss High blood pressure Cancer Alcoholism Psychiatric Illness Others: Yes No Yes No
Left
Yes No Stroke Diabetes
Bleeding problems
Heart Attack
Anesthesia Reaction
Yes No
Acknowledgement and Consent
I
understand that Central Oregon ENT, LLC
(referred to below as “This Practice”) will use and disclose health information about me.
I understand that my health information may include information both created and received by This Practice, may be in
the form of written or electronic records or spoken words, and may include information about my health history, health
status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of healthrelated information.
I understand and agree that This Practice may use and disclose my health information in order to:
• Make decisions about and plan for my care and treatment;
• Remind me of appointments;
• Refer to, consult with, coordinate among, and manage along with other health care providers for my care and
treatment;
• Determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information
to insurance companies or others who may be responsible to pay for some or all of my health care; and
• Perform various office, administrative and business functions that support my physician’s efforts to provide me with,
arrange and be reimbursed for quality, cost-effective health care.
I also understand that I have the right to receive and review a written description of how This Practice will handle
health information about me. This written description is known as a Notice of Privacy Practices and describes the uses
and disclosures of health information made and the information practices followed by the employees, staff and other
office personnel of This Practice, and my rights regarding my health information. I understand that the Notice of Privacy
Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy
Practices. I also understand that a copy of This Practice’s Notice of Privacy Practices in effect will be posted in the waiting/
reception area. I understand that I have the right to ask that some or all of my health information not be used or disclosed
in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to
agree to such requests.
By signing below, I agree that I have reviewed and understand the information above, and that I may request a copy
of the Notice of Privacy Practices from the front office.
Date: By: Patient Signature
- OR -
By: Date: Patient Representative Signature
Description of Representative’s Authority: BEND • 2450 NE Mary Rose Place, Suite 120 • 541.382.3100 | REDMOND • 1523 NW Canal Boulevard, Suite 101 • 541.548.4002
www.coent.com
Financial Agreement
Payment for medical service is due at the time of visit unless prior arrangements have been made.
I authorize Central Oregon ENT, LLC, dba Central Oregon Ear, Nose, & Throat to provide medical treatment for the person
named below and agree to pay all fees and charges for such treatment. I authorize the release of information necessary to
process the insurance claims and secure payment of benefits. I understand that as a courtesy my insurance claims will be
submitted to my insurance carrier. I agree to pay all charges not covered by insurance or other contract medical programs
within ninety days. I also agree that if it becomes necessary to place any past due amount with a collection agency, I am
responsible for any related collection fees.
We participate with many major health plans and will bill your primary insurance as a courtesy. Please contact your health
plan directly for confirmation of coverage, physician participation and covered benefits. It is your responsibility to obtain
any referrals and/or prior authorizations required by your health plan.
I have read, understand and agree to the Financial Policies of CENTRAL OREGON ENT, LLC.
Patient Name:_________________________________________ DOB: __________________________________
Date: ____________________________ Signature: _________________________________________________
Responsible Party
_________________________________________________
Print Name if other than Patient
Financial Policy
Our Financial Policy is outlined below for your information. Please read it carefully. Our Business Office personnel are
available to you; we encourage you to contact us with questions. We will do our best to clarify our policy and avoid
misunderstandings.
PAYMENT
PAYMENT IS EXPECTED AT TIME OF SERVICE. We accept Cash, Checks, Visa & MasterCard.
CO PAYS are due and payable prior to service. A $20 charge is assessed for Co-pays unpaid at time of service.
DEPOSITS are due and collected before services on the following:
¨¨ New Patient: (un-insured)
$250
¨¨ Insurance Deductibles for HSA’s: $250
¨¨ Cancellations with less than 24 hours notice: Payable before new appointment is made ¨¨ Cancelled Surgery: with less than 24 hours notice
¨¨ Office and Hospital Procedures not Covered by Insurance
¨¨ Third Party Liability (i.e. Auto Accident & Personal Injury
$50
$250
$ Cost of Procedure
$250
¨¨ BALANCES for Office Services are collected at check out
¨¨ Collection agency related fees
Approx $50-$100
BEND • 2450 NE Mary Rose Place, Suite 120 • 541.382.3100 | REDMOND • 1523 NW Canal Boulevard, Suite 101 • 541.548.4002
www.coent.com
¨¨ Surgery (for all non-emergent; non-life threatening cases)
¨¨ Insured surgical services
¨¨ Uninsured surgical services
$ Unmet deductible/co-pay
$ 100% of estimated charges
Balance due upon receipt of statement
Payment in full prior to services qualifies for TOS discount.
20% DISCOUNT for PAYMENT IN FULL AT TIME OF SERVICE (TOS)
This discount is offered to our uninsured patients. To qualify, no subsequent insurance processing will be honored.
Checks returned for any reason from the bank will lose this discount.
PATIENT AND INSURANCE BALANCES are due upon of receipt of statement.
CHILDREN & MINORS: The parent or legal guardian must be present for treatment, following state laws. The presenting
parent/guardian is responsible for payment of services. Unaccompanied minors must show ability to pay for services with
cash or supply contact with responsible parent/guardian, who must authorize charges and make any payments due at
time of service.
INSURANCE
Proof of insurance is required; please bring your insurance information with you each time you visit our office. We
participate with many major health plans and will bill your primary insurance as a courtesy. Presentation of proof of
insurance does not exclude requirements of our payment policies listed above. Insurance coverage not presented at time
of visit may not be honored. Please contact your health plan directly for confirmation of coverage, physician participation
and covered benefits. It is your responsibility to obtain any referrals and/or prior authorizations required by your health
plan.