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Cardiology Referring Md: Date: Patient Name: Dob 1001 Main Street, Buffalo, New York 14203 1020 Youngs Road, Williamsville NY 14221 Phone: (716) 961-9900, Fax: (716) 961-9911 CARDIOLOGY REFERRING MD: DATE: PATIENT NAME: DOB: Please help us find out about you by filling out the “Patient” side of this form. Please leave the “Clinician” side blank. PATIENT CLINICIAN Why are you here to see a cardiologist? CC Check off any heart problems or symptoms HPI Heart Attack Angina High Blood Pressure Heart Murmur Rheumatic Fever Abnormal Rhythm (arrhythmia) Palpitations, irregular heartbeats Fainting Enlarged Heart Chest Pains or Pressure Shortness of Breath Dizziness Swollen Legs Heart Failure Blue Lips or Fingernails Leg Cramps When You Walk Have you ever had: A Stress Test An Echocardiogram Cardiac Catheterization/Heart Catheterization Coronary Angioplasty (balloon) Coronary Bypass Surgery Valve Surgery An Electrophysiology Study or Procedure A Pacemaker or Defibrillator Tell us about your risk of heart disease. Please check if you have: High Blood Pressure High Cholesterol Ever Smoked Diabetes Do you exercise (including walking)? YES NO Has a close family member had a heart attack, angina or Bypass surgery? YES NO WHO? _____________________ If you are a woman: HPI (Circle): Brief Extended -Have you passed menopause (Change of life)? YES NO Elements: Location, quality, severity, duration, timing, context, -At what age? _______ Modifying factors, associated signs and symptoms -Do you take estrogen replacement? YES NO Please tell us anything else about your heart: Brief = 1-3 elements; Extended > 4 elements YOUNGS Cardiologist Patient HH Form Page 1 of 3 Revised: 8/21/2015 PATIENT NAME: DOB: PATIENT CLINICIAN Do you have a Health Care Proxy? YES NO Do you have Advanced Directives? YES NO If no, would you like information about it? YES NO Are you being treated now or have been treated for any illness? Please list them: 1. _____________________________________________ Past Med Hx: 2. _____________________________________________ 3. _____________________________________________ 4. _____________________________________________ 5. _____________________________________________ Have you had any operations? Any injuries? 1. _____________________________________________ Past Surg Hx: 2. _____________________________________________ 3. _____________________________________________ 4. _____________________________________________ 5. _____________________________________________ Marital Status: S M W D Social Hx: With whom do you live with? _________________________ Occupation: _______________________________________ Leisure Activities: __________________________________ __________________________________________________ __________________________________________________ Education Level: ___________________________________ Health Habits: Do you Smoke? YES NO If so, how many packs per day? ____________________ For how many years? ____________________________ Do you drink alcohol? YES NO If so, how much? _______________________________ Do you use any illicit drugs? YES NO YOUNGS Cardiologist Patient HH Form Page 2 of 3 Revised: 8/21/2015 PATIENT NAME: DOB: PATIENT CLINICIAN Check if any close family members (parents, brothers, Family Hx: sisters, and children) have: Heart problems High blood pressure Diabetes Cancer Are there any other health problems in your family? __________________________________________________ Are you allergic to any medications? If so please list them: Allergies: __________________________________________________ What kind of reaction did you have? __________________ __________________________________________________ Please list your medications (names, doses or strength and how many times a day you take them). Include over the counter medications and vitamins. _____________________________________________ Medicines: _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Pharmacy: ________________ Phone: ________________ Please CIRCLE any symptoms you have: Lack of energy; trouble sleeping; loss of appetite; weight changes; fevers. Eye problems, such as double or blurred vision; glaucoma; cataracts. Hearing problems; buzzing or ringing in ears. Allergies; hay fever. Sinus problems Breathing problems; indigestion; change in bowel habits. Asthma Stomach problems; indigestion; change in bowel habits. Joint pains, swelling or redness; arthritis; gout. Chest pains; shortness of breath; heart racing or pounding YOUNGS Cardiologist Patient HH Form Page 3 of 3 Revised: 8/21/2015 HIPAA CONTACT AND AUTHORIZATION FOR RELEASE 1001 MAIN STREET 1020 YOUNGS RD. 6105 TRANSIT RD. 300 LINWOOD AVE. 6400 EDGEWOOD DR. 462 GRIDER ST. BUFFALO, NY 14203 WILLIAMSVILLE, NY 14221 E. AMHERST, NY 14051 BUFFALO, NY 14209 NIAGARA FALLS, NY 14304 BUFFALO, NY 14215 P: (716) 961-9900 P: (716) 961-9900 P: (716) 348-3435 P: (716) 961-9400 P: (716) 898-4803 NEPHROLOGY F: (716) 961-9911 F: (716) 961-9911 F: (716) 204-8229 F: (716) 961-9402 F: (716) 898-3928 P: (716) 898-4803 F: (716) 898-3928 BEHAVIORAL MED: P: (716) 898-5671 Patient Name: Date of Birth: / / RECEIPT OF NOTICE OF PRIVACY PRACTICES I have received a copy of the UBMD Internal Medicine, Inc. Notice of Privacy Practice. (also available at UBMDIM.COM) Signature: Date: / / □ Patient refused and/or unable to sign Staff member signature: AUTHORIZATION TO RELEASE INFORMATION TO FAMILY AND/OR FRIENDS Name Relationship Primary Phone Secondary Phone AUTHORIZATION TO LEAVE MESSAGES From time to time it may be necessary to leave you a message concerning appointments, financial issues, or other protected health information (PHI). Please indicate how you prefer we leave a message for you: May we leave a message with another person answering this Phone Number May we leave a voice message? phone? Voice Mail on Preferred Phone Number - - □ Yes □ No □ Yes □ No Voice Mail on Alternate Phone Number - - □ Yes □ No □ Yes □ No May we send a message? Send through US Mail □ Yes □ No RESTRICTIONS TO RELEASE OF INFORMATION Please list any restrictions regarding information to be released: SIGNATURE Signature: Date: / / This authorization shall be in force and effect until revoked by the patient or representative signing the authorization. UBMDIM HIPAA Contact and Authorization for Release, V1 Page 1 of 2 PLEASE SEND TO PREVIOUS PRACTICE Please Name and address of doctor (or other health professional) to release this information (e.g., your previous primary doctor) complete [Type a quote from the document or the summary of an Please complete interesting point. You can position the text box anywhere in the document. Use the Drawing Tools tab to change the formatting of the pull quote text box.] Only if to Atty/Gov Please complete Only if not patient Please Sign/Date UBMDIM HIPAA Contact and Authorization for Release, V1 Page 2 of 2 1020 Youngs Rd. 1001 Main Street 6105 Transit Rd. 300 Linwood Ave. 6400 Edgewood Dr. 462 Grider St. Williamsville, NY 14221 Buffalo, NY 14203 E. Amherst, NY 14051 Buffalo, NY 14209 Niagara Falls, NY 14304 Buffalo, NY 14215 P: 716.961.9900 P: 716.961.9900 P: 716.348.3435 P: 716.961.9400 P: 716.898.4803 Nephrology F: 716.961.9911 F: 716.961.9911 F: 716.204.8229 F: 716.961.9402 F: 716.898.3928 P: 716.898.4803 F: 716.898.3928 Behavioral Med: P: 716.898.5671 UBMD Internal Medicine Patient Agreement Thank you for choosing UBMD Internal Medicine as your and contact you if follow up is needed. Routine lab results may be relayed by postal mail, patient portal or telephone. healthcare provider. Our practice is committed to providing you with the highest quality care, service and Address and/or Phone Number Change access. In order to help accomplish these goals, below Please advise our practice anytime there is a change in is some introductory information and our financial policy. your address, phone number, or other contact information. Our staff is required to verify all demographic and insurance information at every visit. General Information Billing Office: 716.816.7200 Financial Policy Hours: Monday - Friday 7:30 am – 4:30 pm Your clear understanding of our Patient Financial Policy Patient Website: ubmdim.com (available on our Patient Resources web page, or by If you wish to contact a physician regarding a medical request at the office) is important to us. Please ask if you matter, please call the appropriate office above or use the have any questions about our fees, policies, or your Patient Portal (see information on page 2). DO NOT responsibilities. contact physicians via University or buffalo.edu Insurance Verification and Copayments email, as they are not HIPAA-compliant and do not offer Patients are expected to present valid photo identification protection for health information. A medical provider is on and their insurance card at each visit. All co-payments call seven (7) days a week to take urgent calls outside and past due balances are due at the time of check-in normal business hours. Your call will be returned within unless previous arrangements have been made with a one (1) hour. For emergencies, call 911. billing supervisor. Failure to pay your copay at the time of Our phone message is updated as needed to report any service will result in an additional $10 fee. We accept weather-related closings. cash, check, credit card or flexible spending card. No post-dated checks are accepted. A $35 returned check Appointments fee is added to any insufficient funds amount owed by the Please arrive 15 minutes prior to
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