Angott Surgical Associates 88 Wellness Way, Building l

Washington, PA 15301

PATIENT INFORMATION

Last Name First Name Ml ------------ ---------- -----

Address City State Zip Code ----------- --------- --- ----

Date of Birth Social Security# Sex: M/F Marital Status: M D W S ----- ---------

Horne Phone ( ) Cell Phone ( ------

) ______ Work( ) _____ _

Race: ( ) White ( ) Black or African American ( ) Asian ( ) Alaska Native or American Indian ( ) Pacific Islander or Native Hawaiian ( ) Hispanic ( ) Other ( ) Declined

Ethnicity: ( ) Hispanic or Latino ( ) Non-Hispanic or Latino ( ) Declined

Primary Language ----------

Email Address -------------------------------

Emergency Contact ______________ Relationship to Patient _______ _

Emergency Contact Phone Number( )---

Family Physician _____________ Cardiologist ____________ _

Employer -----------------

INSURANCE INFORMATION

PRIMARY INSURANCE ------------------------

Subscriber Relationship Date of Birth ------------ -------- -------

SECONDARY INSURANCE ------------------------

Subscriber Relationship Date of Birth ------------ -------- -------

**IF PATIENT IS A MINOR** Mother's Full Name

----------------------

Fa the r's Full Name -----------------------

Leg a ( Guardian's Full Name --------------------

Address (If different from the patient) -----------------

Pharmacy Name ------------------------------

City Zip Code: ----------------- -------

Date: ------

Name: Date of Birth: ------------------ ---------

YIN

Knee: Hip:

right / left / both (circle) right/ left I both (circle)

Other:

DO YOU TAKE BLOOD THINNERS. Name of drug: (circle) Coumadin Aspirin

Plavix Aggrenox Pradaxa

PROSTHETIC HEART VALVE. Aortic/ mitral (circle) Metal/ porcine/ bovine (circle) Do you take Coumadin? Y / N

YIN

Do you take antibiotics before procedures? Y / N If yes what antibiotic?

rf.1�tlz.1.ifi!itffl4U•1�Wa���i Have you had any problems with anesthesia? Airway problem / breathing / heart / nausea / vomiting

Is there a family history of... (circle) Malignant hyperthermia or Pseudocholinesterase deficiency

Wtl;ffji•Jd•)ll�•i:tii®Ui Do you or does anyone in your family/h ousehold have a history of any of the following:

MRSA ( ) yes VRE ( ) yes C.DIFF ( ) yes

() no () no ( ) no

Tobacco use? ( ) yes ( ) no ( )quit __ year Current smoker:

How many packs per day? ____ _ Former smoker:

How many years did you smoke? Smokeless tobacco? ( )yes ( )no

Do you use alcohol? ( )yes ( )no

---

Daily ___ weekly ___ beer / wine / liquor Substance abuse? Never / current / former Narcotic abuse? Never / current / former Caffeine use: coffee I tea I energy drinks Dietary supplements: ________ _ Vitamins:

-------------

Port Pacemaker I AICD Spinal Cord Stimulator Pain Pump or Insulin Pump

MH§tfflit1 Are you allergic to an of the following? Iodine / fish I eggs / IVP dye Medication Allergy Allergic Reaction

1. 2.

Severity

( options: unsure, mild reactions; rash, hive, itching, nausea, vomiting; severe reactions; fever, throat swelling)

Name: --------------

Past Surgical History

o Appendectomyo Amputationo Arthroscopyo Breast Lumpectomyo Bowel Surgeryo Bypass in Lego Cardiac Bypasso Cardiac Catho Cataractso Colonoscopyo Colon Resectiono C-Sectiono Endometrial Ablationo Endoscopeo Gallbladdero Gastric Bypasso Hemorrhoidectomy

Family History: * Please Check any that apply.

Illness/Type

Cancer:

Ovarian, Breast, Colorectal, Prostate, Other -----High Blood Pressure Heart Disease Diabetes Stroke Mother: Living

·----

Deceased ---Father: Living

·----

Deceased ---

o Hernia Repairo Hysterectomyo Hip Replacemento Knee Replacemento Mastectomyo Pacemakero Pilonidal Cystectomyo Tubal Ligationo Vasectomyo Varicose Vein Stripping

Other Surgeries:

Family Member

1.

2.

3.

Angott Surgical Associates

Acknowledgement of Receipt of Notice of Privacy Practices/Consent to Treat

Angott Surgical Associates has a Notice of Privacy Practices, which describes how we may use and disclose your protected health information and how you can access this information and exercise other rights concerning this information. You may review our current notice prior to signing this acknowledgement. We reserve the right to change our Notice of Privacy Practices and to make the terms of any change effective for all protected health information that we maintain, including information created or obtained prior to the date of the effectiveness of the change.

Acknowledgement of Receipt and Consent

!,.. ____________________________ _..ive my consent to the physicians of Complete Surgical Care to perform medical services determined to be necessary or advisable for the benefit of my health care. Angott Surgical Associates is authorized to use and disclose my protected health information for treatment, payment and health care operations purposes consistent with its Notice of Privacy Practices. I authorize Angott Surgical Associates to bill n:iy insurance carrier and request such payments to be made directly to Angott Surgical Associates. I assigned to Angott Surgical Associates all rights to insurance payments or benefits to which I may be entitled for services provided to me by Angott Surgical Associates. I consent to access by any Angott Surgical Associates affiliate to medical or other information related to my care to be provided to such persons as necessary for them to provide treatment or services to me. I understand that my information may be released if required by local, state or federal law. I consent to and authorized the release of my sensitive medical or other information (Behavior Health and Drug & Alcohol) to my insurance carrier (s) for billing purposes. I consent to have my records released/obtained through Health Information Exchange (HIE), and that I can opt out of HIE upon request. I understand that any amounts not paid by my insurance are my responsibility. I urfderstand that a NO CALL/NO SHOW fee of $25.00 will be billed to me if I do not show up for my scheduled appointment without cancelling.

Medicare/Medicaid Certification Certify that the information given to me in applying for payment under Title XIX of the Social Security Administration Act is correct. authorize any holder of any protected health information about me to release to the Centers for Medicare and Medicaid or its intermediaries or carriers, any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for the physician services to the physician or organization providing the services or authorize that physician or organization to submit a claim to Medicare for payment to me. I give permission for Angott Surgical Associates to obtain a list of my current medications.

Advanced Non-Medicare Beneficiary -

Yes, I want to receive these items or services. I understand that my Insurance Company will not decide whether to pay unless I receive these items or services. Please submit my claim to my insurance company. If my Insurance Company denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand I can appeal my Insurance Company's decision. Please Initial. _________ _

I give permission to the staff of Angott Surgical Associates to release information regarding my medical care, including my medical condition, test results, appointment dates/times to the following individuals and in the selected manner.

Name Relationship Telephone Number

Patient Printed Name Date of Birth Signature Date

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OFFICE USE ONLY

__________________________ Employee Signature