Advanced Rheumatology of Houston

1 Advanced Rheumatology of Houston Offices of Dr. Tamar F Brionez New patient history form Patient name _____DOB _____ Allergies to Medicines: _____ Current Medications Name Dose Times/day taken Social History Married/single/widowed/divorced Number of pregnancies_____ live births _____ Occupation _____ Highest level of education _____ Drug use Y/N, if yes _____ Alcohol consumption (avg # drinks/week) _____ Tobacco Use (packs per week/day) _____ Medical History Please check off all applicable personal medical diagnoses received by a doctor High blood pressure Heart disease Diabetes Thyroid disease Kidney problems COPD/asthma Reflux Stomach ulcers Liver problems Autoimmune Disease (Lupus/RA/Sjogrens/Vasculitis) _____ Frequent infections (please specify) _____ Other _____ Surgical History (please list surgeries and dates) Surgery Date Family History (please list age and health conditions)

2 Mother - Alive/Deceased _____ Father - Alive/Deceased _____ Siblings 1. 2. 3. 4. 5. 6. Family with an autoimmune condition (lupus, rheumatoid arthritis) yes/no If yes, please list I verify that this information is both complete and accurate. Patient Signature: _____Date: _____ Advanced Rheumatology OF Houston Offices of Dr. Tamar Brionez TELEPHONE COMMUNICATION PREFERENCE LOCATION CAN WE CALL HERE? CAN WE LEAVE A MESSAGE?

3 Home Yes No Yes No Work Yes No Yes No Mobile Phone Yes No Yes No Other Yes No Yes No Mail/Email:_____ Advanced Rheumatology OF Houston Offices of Dr. Tamar Brionez So that we may better serve you, please provide the following pharmacy information: Pharmacy name: _____ Street address: _____ City: _____ Zip code: _____ Advanced Rheumatology of Houston Office of Dr.

4 Tamar F Brionez Patient Registration 10857 Kuykendahl Rd Suit 120 The Woodlands, TX 77382 Office: 281-766-7886 Fax: 281-719-9320 () No change in address, phone number Name: (Last) _____ (First) _____(Middle) _____ Address: _____ City: _____ State: _____ Zip: _____ Country: _____ Birthdate: _____ Phone: _____ Work: _____ Fax: _____ Contact by: Phone Mail Fax Email: _____ Sex: M/F Marital Status: Single/Married/Divorced/Widowed/Separate d/Other SSN: _____ Race: Black/Hispanic/Native American/Oriental/Asian/White/Chinese/Fi lipino/Native Hawaiian Multiracial/Pacific Islander/Japanese Language: _____ Employment Status: Full-time/Part-time/Self-employed/Retire d/Student/Child/Unemplyed/Other Responsible Party (Party Responsible for payment): Self/Spouse/Parent/Other Name: (Last) _____ (First) _____ (Middle) _____ Address: _____ City: _____ State: _____ Zip: _____Country: _____ Phone: _____ Work: _____ Fax: _____Email.

5 _____ ( ) No change in insurance information since last visit Primary Insurance: _____ Insured Party: Self/Spouse/Parent/Other Group #: _____ ID: _____ Name: (Last) _____ (First) _____ (Middle) _____ Address: _____ City: _____ State: _____ Zip: _____ Country: _____ Phone: _____ Work: _____ Fax: _____ Secondary Insurance: _____ Insured Party: Self/Spouse/Parent/Other Group #: _____ ID: _____ Name: (Last) _____ (First) _____ (Middle) _____ Address: _____ City: _____ State: _____ Zip: _____ Country: _____ Phone: _____ Work: _____ Fax: _____ Advanced Rheumatology of Houston Acknowledgment of Financial Responsibility This office does not accept responsibility for collection you insurance proceeds or for the negotiating settlement of a disputed claim.

6 If for whatever reason your insurance company does not pay your claim in full, you are responsible for payment of the entire balance including any finance charges or collection fees that may be included. Signature: _____ Date: _ Assignment of Benefits I hereby assign all medical benefits payable for serviced provided by Advanced Rheumatology of Houston including Medicare, private insurance and any other health plans to Advanced Rheumatology of Houston .

7 I further authorize a release of any medical information necessary to process the claim and payment of benefits. A photocopy of this assignment is to be considered as valid as an original. This assignment remains in effect until I revoke in writing. Signature: _____ Date: _ Request for Medical Records/All Additional Paperwork Requests I understand and agree to pay the $25 fee for requesting a hard copy of my medical records and any other additional paperwork I would like the doctor to fill out.

8 I understand that I will need to allow 72 hours for my medical records to be processed and 2 weeks for forms to be filled out. Signature: _____ Date: _____ Medication Refill Policy I understand that should I need any refills on my medications, it should be requested during my appointment with the doctor. I understand that should I make any requests outside of this time, I must allow 3-5 business days for my prescriptions to be filled. I take responsibility to call the office in the appropriate time frame in order for my medications to be refilled before I run out.

9 Signature: _____Date:_____ Please ask the Receptionist for the Notice of the Privacy Practice Acknowledgement of Review of Notice of Privacy Practices I have reviewed this office s notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document. X_____ Signature of Patient or Personal Representative _____ Date _____ Name of Patient or Personal Representative Advanced Rheumatology of Houston Offices of Dr.

10 Tamar F Brionez Authorization for Disclosure of Confidential Information 10857 Kuykendahl Rd Suite 120 The Woodlands, TX 77382 Office: 281-766-7886 Fax: 281-719-9320 Patient Name _____ Address _____ Date of Birth _____ SSN _____ Authorizes: Name of Person/Facility _____ Address or Fax Number _____ To release the following medical information to Advanced Rheumatology of Houston . Check All that May be released: History Lab Reports Operative Report Psychological Reports Physical X-ray Care Plan Progress Notes EKG Report Therapy Reports Other (specify) _____ Note: Memorial Hermann patients must initial the following statement.