briointernalmedicine.com · at brio internal medicine we pride ourselves in offering the best...

N E W P A T I E N T I N F O R M A T I O N

LAST NAME FIRST NAME PREFERRED NAME MIDDLE INITIAL

MAILING ADDRESS CITY/STATE ZIP CODE

CELL PHONE HOME PHONE WORK PHONE

E M E R G E N C Y C O N T A C T

P A T I E N T I N F O R M A T I O N

NAME PHONE NUMBER RELATIONSHIP TO PATIENT

I N S U R A N C E I N F O R M A T I O N

INSURANCE COMPANY SUBSCRIBER NAME MIDDLE INITIAL

GROUP NUMBER SUBSCRIBER NUMBER INSURED DATE OF BIRTH

P R E F E R R E D P H A R M A C Y

PHARMACY NAME LOCATION/ADDRESS PHONE NUMBER

H O W D I D Y O U H E A R A B O U T B R I O ?

9 HAWTHORNE PARK CT GREENVILLE SC 29615 864.603.5600 WWW.BRIOINTERNALMEDICINE.COM

DATE OF BIRTH SS# GENDER PRIMARY LANGUAGE

EMAIL ADDRESS EMPLOYER RACE/ETHNICITY HISPANIC ORIGIN?CIRCLE ONE: Y / N

SECONDARY INSURANCE SUBSCRIBER NAME MIDDLE INITIAL

GROUP NUMBER SUBSCRIBER NUMBER INSURED DATE OF BIRTH

P A T I E N T P R I V A C Y F O R M

PATIENT’S NAME DATE OF B IRTH

S H A R I N G I N F O R M A T I O N


Please list who has permission to receive information from Brio Internal Medicine other than the patient.

Name of person that has permission to receive the above patient information Relationship to patient

Name of person that has permission to receive the above patient information Relationship to patient

R I G H T S O F T H E P A T I E N T

I understand that I have the right to revoke this authorization at any time by sending notification to Brio Internal Medicine 9 Hawthorne Park Ct. Greenville, SC 29615. I understand that a revocation is not effective in cases where the information has already been used or disclosed, but will be effective going forward. I understand that information used or disclosed as a result of this authorization may result in re-disclosure by the recipient and may no longer be protected by federal or state law. Information received by this office is for our own use and will continue to be protected by our Privacy Policy. I understand that I have the right to inspect or copy the protected health information disclosed as described in this docu-ment. I can do this by written notification to: Brio Internal Medicine 9 Hawthorne Park Ct. Greenville, SC 29615. I understand that I have the right to refuse to sign this authorization:

I have read and received a copy of the Notice of Privacy Practices for Brio Internal Medicine.

Signature Date Relationship if not patient

C O M M U N I C A T I O N

I authorize Brio Internal Medicine to provide information regarding: Check ONLY ONEAll information including appointments, general information, updates, billing, etc.Appointment information ONLY

On my: Cell Phone Number Home Phone Number

Brio will send appointment reminders, healthcare updates, & newsletters, via email.Please check here if you DO NOT wish to receive these emails.

Please check here if you DO NOT wish to receive emails about aesthetic services offered at Brio.

Signature of Responsible Party Date

R E S P O N S I B L E P A R T Y A C K N O W L E D G E M E N T

NAME OF RESPONSIBLE PARTY (Please Print) RELAT ION TO PAT IENT(S)


R E S P O N S I B L E P A R T Y

The Responsible Party is the person who is FINANCIALLY responsible for the patient’s account(s) and who will receive all account statements to their address. By signing, I understand that I am the responsible party and will adhere to the requirements outlined in the policies provided to me for the following patient(s) as well as future patients registered in my name at Brio Internal Medicine. If you are 18 or older, you are your own responsible party.

W A I V E R O F L I A B I L I T Y

I understand that the treatment/service from the providers and physicians at Brio Internal Medicine for the patient(s) listed above may not be a covered treatment/service or may not be covered at 100%. I agree to be personally and fully responsible for any balance due.

P A Y M E N T P O L I C Y

Brio Internal Medicine is committed to providing the best treatment for our patients. Our pricing structures are repre-sentative of the ususal and customary charges for our area. Thank you for adhering to our payment policy. Signing below indicates that you are the responsible party which means you are financially responsible for this patient and have read and understand the payment policy and agree to abide by its guidelines.

R E S P O N S I B L E P A R T Y A C K N O W L E D G E M E N T

I understand that I am the responsible party for the patient(s) listed above and any future patient(s) registered in my name at Brio Internal Medicine and I agree to the terms of the Waiver of Liability and Payment Policy. I have been given a copy for review and I am aware of the availability of these documents in the office of Brio Internal Medicine as well as online atwww.briointernalmedicine.com.

Responsible Party Initials

Responsible Party Initials

Signature of New Patient Date

N E W P A T I E N T A P P O I N T M E N T S

I understand that the typical new patient visit is a consultation in which your new provider will take the time to get to know you personally as well as your medical issues. Devoting this extra time at your initial visit allows us to gain a solid foundation of your health information that will result in us providing you with the highest quality care. After your initial consultation, we will togeth-er determine when labwork, additional testing, and/or a physical are needed.

Controlled Substances Policy of Brio Internal Medicine

Patient Name: ________________________ SSN: __________________

Your physician believes that a drug, which is a “controlled” medication, is indicated for your current or possible future pain relief or similar medical issue. Controlled medicine can be

dangerous and habit forming. These medicines must be taken only as prescribed by your doctor. Please read this policy thoroughly and ask questions you may have.

If you are in agreement and fully understand the benefits and risks sign and date below.

I understand that the medication I am being prescribed may cause addiction, but my physician feels it is necessary for treatment of my condition: I agree to accept this risk.

I agree to take this medication only as prescribed by my physician.

I agree to attend all scheduled appointments with my physician or PA.

I understand refills will not be given early. After initiation of treatment, the patient will follow up every 90 days prior to the issuance of refills of medication prescribed for the treatment. The patient will not be permitted to schedule past 90 days unless extenuating circumstances. Merely scheduling a follow-up appointment does not satisfy this requirement.

Medication prescriptions cannot be mailed, faxed or called into the pharmacy.The prescription must be picked up at Brio Internal Medicine by the patient and picture ID must be shown.

I will not seek controlled substances from any other physician. I understand that it isillegal for me to seek controlled substances from more than one doctor at the same time.

I understand that these medications are for my personal use only and only for the relief ofthe pain.

I agree not to share my medications with somebody else. I agree to keep my medications away from children and not to share my medications withfamily or friends.

I agree to safely dispose of my medications if necessary.

I understand that it is illegal to give or sell my medications to others.

I agree to not use any illegal substances, including but not limited to, marijuana, cocaine,or any other “street” drugs.

atient initial canned by ate

I understand that is illegal for me to use medications prescribed to other people.

I understand that I am responsible for my own medication. Lost or stolen medications willnot be replaced. rio Internal edicine is to be promptly notified in the e ent that the medication prescription or prescribed medication is lost stolen or rendered unusable. uch an occurrence will be thoroughly e aluated by the physician prior to the issuance of a replacement prescription.

I gi e up the right to pri acy in this matter. he physician or her staff may tal with other medical doctors pharmacists or family members to confirm appropriate medication use.

I agree to random drug screening test when ordered by my physician and I will beresponsible for payment of the test.

If re uested of me I agree to bring my pill bottle s to the office for the purpose of a pillcount.

I understand that I may obtain my controlled substances from only one pharmacy and Iagree to pro ide the following information and update rio Internal edicine of anychanges.

I understand these medications may interfere with my ability to dri e and or operatehea y machinery.

I agree to immediately notify my physician if I e perience any symptoms or side effects.i e your current pharmacy information below. d ise of updates on each isit.

ou must pro ide a daytime telephone number where you can be reached during normal business hours.

I have read the above Controlled Substance Policy. I understand that failure to follow the above guidelines after one occurrence may result in being discharged from Brio Internal Medicine.

Patient Signature _______________________________ Date ______________

Witnessed by: ________________________________________

Home: _____________________ Cell: ___________________ Work: _______________

Pharmacy Name: Phone#/Location

atient initial canned by ate

Patient Name:______________________________

DOB:____________

LABS. Did you know?

At Brio Internal Medicine we pride ourselves in offering the best healthcare possible to our patients. By doing this, our providers may at times desire for you to have labs drawn, whether for preventative or diagnostic care.

Although we feel like these labs are a very important part of your healthcare,these labs may not be covered by some insurance companies. In the event that your labs are not covered by your insurance company you will receive a bill from Brio Internal Medicine, LabCorp, or both.

For any lab bill you receive from Brio Internal Medicine that is not covered by insurance, you will be given a 20% discount on that lab bill (this does not include bills from LabCorp).

By signing this form, you are accepting responsibility for any uncoveredexpenses associated with these labs.

_____________________________________ ____________________Patient Signature Date

Patient Center Medical Home FACT SHEET

What is a patient centered medical home? The Medical Home is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.

At Brio, we understand the importance of having a consistent medical home. This means that we work together as a team to provide the most comprehensive care for every patient. Our team includes our Brio providers, nurses, medical assistants, and staff, as well as other external referred resources and specialists, and the most important member – the patient! We act as a central hub of information and care to ensure that all areas (physical, psychological, emotional, and developmental, etc.) are being addressed and monitored over the long term. This is a proven way to detect any areas of concern as well as build trust and establish a long-term relationship with the patient as part of the Brio family.

As a Medical Home we will also help find needed information and resources, such as information about:

• Specialists• Health conditions/latest treatments• Home care, equipment, and vendors• Supports and respite services for your family• Other key local services

We will also:

• Take care of every patient when he or she is sick or well and help promotewellness

• Help plan the patient’s care and/or set goals for care, now and for the future• Talk with patient and family about any testing or treatment that is needed• Work with patient and family and other care providers to coordinate care

For more information please reference this website: http://www.medicalhomeinfo.org/

Link to video about Patient Centered Medical Home: http://www.emmisolutions.com/medicalhome/transformed/index.html

http://www.medicalhomeinfo.org/

http://www.emmisolutions.com/medicalhome/transformed/index.html

P R I V A C Y N O T I C E

H I P A A P O L I C Y S T A T E M E N T


B r i o I n t e r n a l M e d i c i n e P . A . ’ s P r i v a c y N o t i c e t o P a t i e n t s

T H I S N O T I C E D E S C R I B E S H O W Y O U R M E D I C A L I N F O R M A T I O N M A Y B E U S E D A N D D I S C L O S E D B Y B R I O I N T E R N A L M E D I C I N E A N D H O W Y O U C A N G E T A C C E S S T O T H I S I N F O R M A T I O N . P L E A S E R E A D I T C A R E F U L L Y .

E f f e c t i v e D a t e : O c t o b e r 5 , 2 0 1 5U n d e r t h e H I P A A P r i v a c y r e g u l a t i o n s , B r i o I n t e r n a l M e d i c i n e a n d a l l s i m i l a r h e a l t h c a r e p r o v i d e r s a r e r e q u i r e d b y f e d e r a l l a w t o m a i n t a i n p r i v a c y o f y o u r p r o t e c t e d h e a l t h i n f o r m a t i o n ( P H I ) a n d w i l l a b i d e b y t h e t e r m s i n t h e P r i v a c y N o t i c e . P l e a s e b e a d v i s e d t h a t B r i o I n t e r n a l M e d i c i n e m a y u s e y o u r P H I i n r e n d e r i n g t r e a t m e n t . F o r e x a m p l e , w e a r e p e r m i t t e d t o u s e y o u r P H I i n p r o v i d i n g y o u w i t h m e d i c a l c a r e / t r e a t m e n t w h e n y o u v i s i t o u r o f f i c e o r w h e n w e t r e a t y o u i n a h o s p i t a l o r n u r s i n g f a c i l i -t y . U n d e r f e d e r a l l a w , w e m a y d i s c l o s e y o u r P H I t o y o u o r w e c a n d i s c l o s e y o u r P H I t o t h i r d p a r t i e s f o r t r e a t m e n t . F o r e x a m -p l e , i f w e r e f e r y o u t o a s p e c i a l i s t , w e w i l l f o r w a r d y o u r m e d i c a l i n f o r m a t i o n t o s u c h s p e c i a l i s t s . W e c a n d i s c l o s e y o u r P H I f o r p a y m e n t p u r p o s e s . F o r e x a m p l e , w e w i l l d i s c l o s e y o u r P H I t o y o u r i n s u r a n c e p r o v i d e r , y o u r e m p l o y e r , M e d i c a r e , M e d i c -a i d , o r o t h e r p a r t i e s r e s p o n s i b l e f o r p r o v i d i n g y o u w i t h h e a l t h i n s u r a n c e c o v e r a g e i n o r d e r f o r B r i o I n t e r n a l M e d i c i n e t o b e r e i m b u r s e d f o r o u r s e r v i c e s r e n d e r e d t o y o u . W e w i l l a l s o u s e o r d i s c l o s e y o u r P H I f o r h e a l t h c a r e o p e r a t i o n s . F o r e x a m p l e , w e m a y u s e y o u r P H I w h e n w e e n g a g e i n q u a l i t y a s s u r a n c e a n d m e d i c a l c h a r t r e v i e w s , w h i c h a r e p a r t o f o u r h e a l t h c a r e o p e r a t i o n s . W e m a y a l s o d i s c l o s e y o u r P H I , w h e n r e q u i r e d b y t h e S e c r e t a r y o f t h e U S D e p a r t m e n t o f H e a t l h & H u m a n S e r v i c e s . U n l e s s d i s c l o s u r e i s r e q u r i e d u n d e r f e d e r a l / s t a t e l a w , o r c e r t a i n o t h e r e x c e p t i o n s , i n c l u d i n g l a w e n f o r c e m e n t , w e a r e p r o h i b i t e d f r o m d i s c l o s i n g y o u r P H I w i t h o u t y o u r a u t h o r i z a t i o n . O u r p r a c t i c e m a y u s e o r d i s c l o s e y o u r P H I i n a c c o r d a n c e w i t h t h e s p e c i f i c r e q u i r e m e n t s o f t h e H I P A A r u l e s w i t h o u t B r i o I n t e r n a l M e d i c i n e n e e d i n g t o o b t a i n y o u r a u t h o r i z a t i o n i f t h e i n f o r m a t i o n i s :1 . r e q u i r e d b y l a w2 . r e q u i r e d f o r p u b l i c h e a l t h p u r p o s e s3 . r e q u i r e d d i s c l o s u r e s a b o u t v i c t i m s o f a b u s e , n e g l e c t o r d o m e s t i c v i o l e n c e4 . r e q u i r e d b y h e a l t h o v e r s i g h t a g e n c y f o r o v e r s i g h t a c t i v i t i e s a u t h o r i z e d b y l a w5 . r e q u i r e d i n t h e c o u r s e o f a n y j u d i c i a l o r a d m i n i s t r a t i v e p r o c e e d i n g6 . r e q u i r e d f o r a l a w e n f o r c e m e n t p r u p o s e t o a l a w e n f o r c e m e n t o f f i c i a l7 . r e q u i r e d b y a c o r o n e r o r m e d i c a l e x a m i n e r8 . r e q u i r e d b y a n o r g a n p r o c u r e m e n t o r g a n i z a t i o n f o r r e s e a r c h , a n d9 . n e c e s s a r y t o p r e v e n t o r l e s s e n a s e r i o u s a n d i m m i n e n t t h r e a t t o t h e h e a l t h o r s a f e t y o f a p e r s o n o r t h e p u b l i c .A d d i t i o n a l l y , i f y o u a r e a m e m b e r o f t h e a r m e d f o r c e s , B r i o I n t e r n a l M e d i c i n e i s p e r m i t t e d t o d i s c l o s e y o u r P H I w i t h o u tc o n s e n t i f d e e m e d n e c e s s a r y b y a p p r o p r i a t e m i l i t a r y c o m m a n d a u t h o r i t i e s t o a s s u r e a n a p p r o p r i a t e m i l i t a r y m i s s i o n . W em a y a l s o c o n t a c t y o u v i a m a i l o r p h o n e t o r e m i n d y o u o f a p p o i n t m e n t s w i t h o u r o f f i c e o r t o d i s c u s s t r e a t m e n t a l t e r n a t i v e s .I f , f o r a n y r e a s o n , y o u d o n o t w i s h t o b e c o n t a c t e d v i a m a i l o r p h o n e , o u r o f f i c e p e r s o n n e l w i l l n o t e y o u r r e q u e s t i n y o u rc h a r t . I n t h e e v e n t o u r p r a c t i c e w i s h e s t o d i s c l o s e y o u r P H I t o a n o t h e r e n t i t y b e s i d e s t h o s e r e f e r e n c e d a b o v e , w e a r er e q u i r e d t o o b t a i n y o u r a u t h o r i z a t i o n . W e w o u l d s e e k t o o b t a i n y o u r a u t h o r i z a t i o n i f B r i o I n t e r n a l M e d i c i n e d e c i d e d t or e l e a s e y o u r P H I f o r r e a s o n s o t h e r t h a n t r e a t m e n t , p a y m e n t , o r f o r o u r p r a c t i c e ’ s o p e r a t i o n s . F o r e x a m p l e , i f w e d e s i r e d t op a r t i c i p a t e i n o u t s i d e r e s e a r c h o r a d r u g s t u d y , w e w o u l d n e e d y o u r w r i t t e n a u t h o r i z a t i o n p r i o r t o b e i n g p e r m i t t e d t or e l e a s e y o u r P H I t o s u c h o u t s i d e r e s e a r c h f a c i l i t y o r d r u g m a n u f a c t u r e r . I f y o u p r o v i d e u s w i t h a n a u t h o r i z a t i o n , y o u h a v et h e a b i l i t y t o r e v o k e s u c h a u t h o r i z a t i o n a t a n y t i m e b y s e n d i n g B r i o I n t e r n a l M e d i c i n e a w r i t t e n r e v o c a t i o n . H o w e v e r , i f w eh a v e a l r e a d y r e l e a s e d s u c h i n f o r m a t i o n p u r s u a n t t o y o u r p r i o r a u t h o r i z a t i o n , t h e r e v o c a t i o n w i l l b e e f f e c t i v e f o r a l l f u t u r ed i s c l o s u r e s . P l e a s e b e f u r t h e r a d v i s e d t h a t y o u h a v e t h e a b i l i t y t o a c c e s s , o b t a i n a c o p y , i n s p e c t a n d r e q u e s t a m e n d m e n tt o y o u r m e d i c a l i n f o r m a t i o n t h a t w e m a i n t a i n . A d d i t i o n a l l y , i f y o u d e s i r e , B r i o I n t e r n a l M e d i c i n e c a n p r o v i d e y o u w i t h a na c c o u n t i n g o f a l l d i s c l o s u r e s f o r t r e a t m e n t , p a y m e n t o r h e a l t h c a r e o p e r a t i o n s p u r s u a n t t o a u t h o r i z a t i o n . I f y o u h a v e ad i s p u t e w i t h o u r p r a c t i c e r e g a r d i n g t h e u s e o f y o u r P H I o r a d i s c l o s u r e b y B r i o I n t e r n a l M e d i c i n e a n d b e l i e v e t h a t y o u rp r i m a r y r i g h t s h a v e b e e n v i o l a t e d , p l e a s e c o n t a c t B r i o I n t e r n a l M e d i c i n e t o f i l e a c o m p l a i n t o r y o u m a y c o n t a c t t h e S e c r e -t a r y o f H e a l t h a n d H u m a n S e r v i c e s . W e w e l c o m e f e e d b a c k f r o m o u r p a t i e n t s t h r o u g h o u r w e b s i t e c o n t a c t u s f o r m o r v i ae m a i l a t i n f o @ b r i o i n t e r n a l m e d i c i n e . c o m . P l e a s e u n d e r s t a n d t h a t B r i o I n t e r n a l M e d i c i n e w i l l n o t r e t a l i a t e a g a i n s t y o u i n a n yw a y f o r f i l i n g a c o m p l a i n t . L a s t l y , p l e a s e b e a d v i s e d t h a t y o u h a v e t h e r i g h t t o d e s i g n a t e a p e r s o n a l r e p r e s e n t a t i v e o rr e q u e s t r e s t r i c t i o n s o n c e r t a i n u s e s a n d d i s c l o s u r e s o f y o u r P H I t o c a r r y o u t t r e a t m e n t , p a y m e n t o r h e a l t h c a r e o p e r a t i o n s o rd i s c l o s u r e s b y B r i o I n t e r n a l M e d i c i n e o f y o u r P H I t o a f a m i l y m e m b e r , r e l a t i v e , o r a c l o s e p e r s o n a l f r i e n d . H o w e v e r , w e a r en o t r e q u i r e d b y f e d e r a l l a w t o a g r e e t o y o u r r e q u e s t e d d e s i g n a t i o n o r r e s t r i c i t i o n . I f y o u r e q u e s t a c o p y o f y o u r P H I , y o ua l s o h a v e t h e a b i l i t y t o r e q u e s t t h a t w e s e n d i t t o a n a l t e r n a t i v e l o c a t i o n ( d i f f e r e n t a d d r e s s ) a n d b y a l t e r n a t i v e m e a n s .A d d i t i o n a l l y , i f y o u h a v e r e c e i v e d t h i s n o t i c e i n a n e l e c t r o n i c f o r m a n d y o u w o u l d l i k e a p a p e r c o p y , p l e a s e c o n t a c t B r i oI n t e r n a l M e d i c i n e ’ s P r i v a c y C o n t a c t . B r i o I n t e r n a l M e d i c i n e r e s e r v e s t h e r i g h t t o a m e n d t h i s n o t i c e a s r e v i s e d . N o t i c e s w i l lb e p o s t e d o n o u r w e b s i t e ( w w w . b r i o i n t e r n a l m e d i c i n e . c o m ) a n d i n o u r o f f i c e s a n d p r o v i d e d t o y o u u p o n y o u r r e q u e s t .T h a n k y o u a n d i f y o u h a v e a n y q u e s t i o n s , p l e a s e c o n t a c t B r i o I n t e r n a l M e d i c i n e a t 8 6 4 - 6 0 3 - 5 6 0 0 .

P A Y M E N T P O L I C YP A Y M E N T P O L I C Y

P R O O F O F I N S U R A N C E :A l l p a t i e n t s m u s t co m p l e t e o u r p a t i e n t i n f o r m a t i o n f o r m s b e f o r e s e e i n g t h e p r o v i d e r . W e m u s t o b t a i n a c o p y o f y o u r c u r r e n t , v a l i d i n s u r a n c e c a r d f o r p r o o f o f i n s u r a n c e . I f y o u f a i l t o p r o v i d e u s w i t h t h e c o r r e c t i n s u r a n c e i n f o r m a t i o n a t t h e t i m e o f s e r v i c e , y o u m a y b e r e s p o n s i b l e f o r t h e b a l a n c e o f y o u r c l a i m .

C O P A Y M E N T S A N D B A L A N CE S D U E :A l l c o p a y m e n t s a n d b a l a n c e d u e s m u s t b e p a i d a t t h e t i m e o f s e r v i c e . T h i s a r r a n gem e n t i s p a r t o f y o u r c o n t r a c t w i t h y o u r i n s u r a n c e c o m p a n y . F a i l u r e o n o u r p a r t t o co l l e c t c o p a y m e n t s f r o m p a t i e n t s c a n b e c o n s i d e r e d f r a u d . P l e a s e h e l p u s i n u p h o l d i n g t h e l a w b y p a y i n g y o u r c o p a y m e n t a t e a c h v i s i t .

C L A I M S U B M I S S I O N :W e w i l l s u b m i t y o u r c l a i m s t o y o u r i n s u r a n c e p r o v i d e r a n d a s s i s t y o u i n a n y w a y w e r e a s o n a b l y c a n t o h e l p g e t y o u r c l a i m s p a i d . Y o u r i n s u r a n c e c o m p a n y m a y n e e d y o u t o s u p p l y c e r t a i n i n f o r m a t i o n d i r e c t l y . I t i s y o u r r e s p o n s i b i l i t y t o c o m p l y w i t h t h e i r r e q u e s t . P l e a s e b e a w a r e t h a t t h e b a l a n c e o f y o u r c l a i m i s y o u r r e s p o n s i b i l i t y w h e t h e r o r n o t y o u r i n s u r a n c e c o m p a n y p a y s y o u r c l a i m . Y o u r i n s u r a n c e b e n e f i t i s a c o n t r a c t b e t w e e n y o u a n d y o u r i n s u r a n c e co m p a n y ; w e a r e n o t a p a r t y t o t h a t c o n t r a c t .

M O N T H L Y B I L L I N G S T A T E M E N T :A f t e r y o u r i n s u r a n c e co m p a n y p a y s B r i o I n t e r n a l M e d i c i n e , y o u w i l l r e c e i v e a m o n t h l y b i l l i n g s t a t e m e n t , w h i c h i n d i -c a t e s y o u r b a l a n c e d u e a n d / o r d e d u c t i b l e d u e . T h e s e a m o u n t s a r e p a y a b l e t o B r i o I n t e r n a l M e d i c i n e . T h e b a l a n c e d u e i s p a y a b l e i n f u l l w i t h i n 1 0 d a y s o f r e c e i p t o f t h e m o n t h l y b i l l i n g s t a t e m e n t . I f y o u h a v e q u e s t i o n s a b o u t y o u r a c c o u n t p l e a s e c a l l 8 6 4 - 6 0 3 - 5 6 0 0 .

I N S U R A N C E :W e p a r t i c i p a t e i n m o s t i n s u r a n c e p l a n s . I f y o u a r e n o t i n s u r e d b y a p l a n w e d o b u s i n e s s w i t h o r d o n o t h a v e i n s u r a n c e , p a y m e n t i n f u l l i s e x p e c t e d a t e a c h v i s i t . I f y o u a r e i n s u r e d b y a p l a n w e d o b u s i n e s s w i t h b u t d o n ’ t h a v e a n u p - t o - d a t e i n s u r a n c e c a r d , p a y m e n t i n f u l l f o r e a c h v i s i t i s r e q u i r e d u n t i l w e c a n v e r i f y y o u r c o v e r a g e . B r i o I n t e r n a l M e d i c i n e w i l l f i l e t o y o u r p r i m a r y a n d s e c o n d a r y i n s u r a n c e .

C O V E R A G E C H A N G E :I f y o u r i n s u r a n c e c h a n g e s , p l e a s e n o t i f y u s b e f o r e y o u r n e x t v i s i t s o w e c a n m a k e t h e a p p r o p r i a t e c h a n g e s t o h e l p y o u r e c e i v e y o u r m a x i m u m b e n e f i t s . I f w e c a n n o t v e r i f y a c t i v e c o v e r a g e , t h e b a l a n c e w i l l a u t o m a t i c a l l y b e b i l l e d t o y o u .

N O N - P A Y M E N T :P a r t i a l p a y m e n t s w i l l n o t b e a c c e p t e d u n l e s s o t h e r w i s e n e g o t i a t e d w i t h t h e b i l l i n g d e p a r t m e n t . P l e a s e b e a w a r e t h a t i f a b a l a n c e r e m a i n s u n p a i d , w e m a y r e f e r y o u r a c c o u n t t o a c o l l e c t i o n a g e n c y a n d y o u m a y b e d i s c h a r g e d f r o m t h i s p r a c t i c e . Y o u w i l l b e r e s p o n s i b l e f o r a n y c o l l e c t i o n o r l e g a l c o s t a s s o c i a t e d w i t h c o l l e c t i n g y o u r a c c o u n t . I f t h i s i s t o o c c u r , y o u w i l l b e n o t i f i e d t h a t y o u h a v e 3 0 d a y s t o f i n d a l t e r n a t i v e m e d i c a l c a r e . D u r i n g t h a t 3 0 d a y p e r i o d , o u r p r o v i d e r s w i l l o n l y b e a b l e t o t r e a t y o u o n a n e m e r g e n c y b a s i s .

M I S S E D A P P O I N T M E N T S :I n o r d e r t o a c h i e v e t h e b e s t a p p o i n t m e n t a v a i l a b i l i t y f o r o u r p a t i e n t s , w e h a v e a p o l i c y f o r m i s s e d a p p o i n t m e n t s . T h e r e w i l l b e a $ 5 0 c h a r g e a d d e d t o t h e a c c o u n t f o r a m i s s e d a p p o i n t m e n t . T h r e e m i s s e d a p p o i n t m e n t s w i t h i n a 1 2 m o n t h p e r i o d w i l l r e s u l t i n e l i g i b i l i t y f o r d i s c h a r g e f r o m t h e p r a c t i c e f o r t h e f a mi l y . W e u n d e r s t a n d t h e p o t e n t i a l f o r u n f o r e s e e n c i r c u m s t a n c e s t h a t c a n a r i s e t h a t m a y c a u s e a l a t e a r r i v a l o r m i s s e d a p p o i n t m e n t . I f t h i s h a p p e n s , p l e a s e c a l l u s a s s o o n a s p o s s i b l e s o w e c a n c h a n g e y o u r a p p o i n t m e n t s t a t u s a c c o r d i n g l y a n d m a k e i t a v a i l a b l e f o r a n o t h e r p a t i e n t . I f t h e f i r s t N e w P a t i e n t A p p o i n t m e n t i s m i s s e d , t h e i n d i v i d u a l w i l l n o l o n g e r b e e l i g i b l e t o s t a y w i t h B r i o a s a p a t i e n t o f t h e p r a c t i c e .C A N C E L L A T I O N S :O u r p o l i c y i s t o c h a r g e $ 2 5 f o r p r e v i o u s l y s c h e d u l e d a p p o i n t m e n t s t h a t a r e c a n c e l e d l e s s t h a n 2 4 h o u r s p r i o r t o t h e i r s c h e d u l e d t i m e / d a t e . T h e s e c h a r g e s w i l l b e y o u r r e s p o n s i b i l i t y a n d b i l l e d d i r e c t l y t o y o u , a n d n o t y o u r i n s u r a n c e c o m p a n y . P l e a s e h e l p u s s e r v e y o u b e t t e r b y k e e p i n g y o u r r e g u l a r l y s c h e d u l e d a p p o i n t m e n t s .

N O N - C O V E R E D S E R V I C E S :P l e a s e b e a w a r e t h a t s o m e - a n d p e r h a p s a l l - o f t h e s e r v i c e s y o u r e c e i v e m a y b e n o n - c o v e r e d o r n o t c o n s i d e r e d r e a s o n a b l e o r n e c e s s a r y b y y o u r i n s u r a n c e c o m p a n y . S i n c e a l l i n s u r a n c e p l a n s a r e d i f f e r e n t , p l e a s e c o n t a c t y o u r i n s u r a n c e c o m p a n y o r H R d e p a r t m e n t f o r d e t a i l e d i n f o r m a t i o n a b o u t w h a t i s c o v e r e d o r n o t c o v e r e d i n c l u d i n g a n n u a l p h y s i c a l m a x i m u m s , i m m u n i z a t i o n s , e t c . Y o u w i l l b e b i l l e d a n d r e s p o n s i b l e f o r a l l n o n - c o v e r e d s e r v i c e s . W e c h a r g e a $ 1 5 f e e i n o r d e r t o f i l l o u t f o r m s t h a t a r e b r o u g h t i n t o t h e o f f i c e o u t s i d e o f an a p p o i n t m e n t .

F O R M S O F P A Y M E N T :B r i o I n t e r n a l M e d i c i n e a c c e p t s p a y m e n t s b y c a s h , c h e c k , m o n e y o r d e r s , V i s a , M a s t e r C a r d , A m e r i c a n E xp r e s s , D i s c o v e r , a n d d e b i t c a r d s b e a r i n g t h e s e l o g o s . P a y m e n t i s e x p e c t e d a t t i m e o f s e r v i c e .

M E D I C A L H I S T O R Y


M E D I C A L I N F O R M A T I O N


PERSONAL MEDICAL HISTORY-Please circle existing medical problems.

High Blood Pressure Diabetes Cholesterol Problems Stroke Reflux/Heartburn Anemia Heart Disease MenopauseOsteoarthritis Allergies Osteoporosis Sinus DiseaseCancer (Type___________) Psoriasis Rheumatiod Arthritis SeizuresHypothyroidism Liver Disease Kidney Disease MigrainesHeadaches COPD/Asthma Diverticulosis DepressionIrritable Bowel Syndrome Anxiety Bipolar Eczema

PREVENTATIVE CARE-Please list the date of most recent procedures and immunizations.Pap Smear_____________________________________________ Tdap ______________________________________Mammogram__________________________________________ Pneumovax________________________________Bone Density___________________________________________ Prevnar____________________________________Colonoscopy___________________________________________ Zostavax___________________________________

SPECIALISTS-List any specialist you are currently seeing and the reason.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please circle any symptoms you have had recently.

Significant Weight Loss/Gain Fever/Chills Night SweatsExcessive Fatigue Insomnia Loss of AppetiteHeadaches Blurred Vision Glasses/ContactsDouble Vision Ringing in Ears Hearing LossSinus Drainage Sore Throat HoarsenessChest Pain Palpitations Leg SwellingShort of Breath Cough/Sputum WheezingSevere Heartburn Difficulty Swallowing NauseaVomiting Constipation DiarrheaBloody Stools Black Stools Abdominal PainPainful Urination Blood in Urine Difficulty VoidingBreast Change/Discharge Menstrual Changes Hot FlashesLoss of Balance Dizziness BlackoutsProlonged Numbness Seizures Sexual ProblemsDepression Anxiety TremorRashes/Mole Changes Joint Pains/Swelling Easy Bruising

M E D I C A L H I S T O R Y



S O C I A L M E D I C A L H I S T O R Y

Yes No Do you currently smoke or use tobacco products? If yes, how many per day?__________________ Yes No Have you smoked or used tobacco products in the past? If yes how many per day?____________

How many years have you smoked?___________________________________________________ Yes No Do you drink caffeinated beverages? If yes, what type, how often/much?_____________________ Yes No Do you drink alcohol? If yes, what type, how often/much?_____________________________________ Yes No Do you exercise regularly? If yes, what type?__________________________________________________

How often and how long?_____________________________________________________________

1._____________________________________________________________________ Year_____________2._____________________________________________________________________ Year_____________3._____________________________________________________________________ Year_____________4._____________________________________________________________________ Year_____________5._____________________________________________________________________ Year_____________6._____________________________________________________________________ Year_____________Did you have any problems with anesthesia? If yes, please describe: _____________________________________________________________________________________________________________________________

S U R G I C A L & H O S P I T A L I Z A T I O N H I S T O R Y - List all hospital admissions and operations.

M E D I C A T I O N S - Please list all medications you are currently taking.

MEDICATION NAME DOSAGE FREQUENCY__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

A L L E R G I E S - Please list all medication, environmental, and any other allergies. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

F A M I L Y M E D I C A L H I S T O R Y


M E D I C A L I N F O R M A T I O N


FAMILY MEDICAL HISTORY-Has anyone in your close family experienced the following:

High Blood Pressure No Yes Who_______________________________________High Cholesterol No Yes Who_______________________________________Heart Disease No Yes Who_______________________________________Stroke No Yes Who_______________________________________Migraines No Yes Who_______________________________________Seizures/Convulsions No Yes Who_______________________________________Diabetes No Yes Who_______________________________________Bleeding/Blood-clotting Disorder No Yes Who_______________________________________Allergies No Yes Who_______________________________________Asthma No Yes Who_______________________________________Thyroid Problems No Yes Who_______________________________________Osteoporosis No Yes Who_______________________________________Pyschiatric Disorder/Mental Illness No Yes Who_______________________________________Alzheimer’s/Dementia No Yes Who_______________________________________Cancer-type:_________________ No Yes Who_______________________________________Other: No Yes Who_______________________________________

Please list any other medical history that you consider important to share: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICAL RECORDS RELEASE AUTHORIZATION

Last Name First Name Date of Birth

PLEASE RELEASE ALL MEDICAL RECORDS FOR TRANSFER OF PATIENT CARE

FROM: Name of Practice Phone Fax

TO:

Please release a copy of all medical records, including but not limited to: all records, progress notes, operative notes, laboratory/x-ray results, and diagnostic tests. This authorization is valid from the date of this document and will expire 180 days after that date.

BY MY SIGNATURE I AUTHORIZE RELEASE OF ALL MEDICAL RECORDS and agree that I have been offered a copy of this document as it is available in the office of Brio Internal Medicine as well as online at www.briointernalmedicine.com.I am aware that some of this information may contain sensitive material with regard to alcohol and drug abuse, sexually transmitted diseases, behavior or mental health, HIV/AIDS, hepatitis, or other communicable diseases.

Patient Signature: Date:

Rights of the Patient:I understand that I have the right to revoke this authorization at any time by sending notification to Brio Internal Medicine 9 Hawthorne Park Ct. Greenville, SC 29615. I understand that a revocation is not effective in cases where the information has already been used or disclosed, but will be effective going forward. I understand that my treatment, payment, enrollment, or eligibility is not dependent on whether or not I sign this authoriza-tion. I understand that information used or disclosed as a result of this authorization may result in re-disclosure by the recipient and may no longer be protected by federal or state law. Information received by this office is for our own use and will continue to be protected by our Privacy Policy. I understand that I have the right to inspect or copy the protected health information disclosed as described in this document. I can do this by written notification to: Brio Internal Medicine 9 Hawthorne Park Ct. Greenville, SC 29615. I understand that I have the right to refuse to sign this authorization.

BRIO INTERNAL MEDICINE 9 Hawthorne Park Court, Greenville, SC 29615

Phone: 864.603.5600 Fax: 864.603.5601www.briointernalmedicine.com

Name of Practice Phone Fax

briointernalmedicine.com · at brio internal medicine we pride ourselves in offering the best...

Documents