Cascade ENT New Patient Paperwork Welcome to Cascade ENT Our office is located at 431 NE Revere Ave. Ste. 100, Bend, OR 97701. We look forward to meeting you. When you check in on the day of your appointment, please be sure and bring the physical copy of your insurance card to your appointment for us to scan into your chart. A digital copy of your insurance card is not sufficient, it must be the physical copy of your card. If the physical copy is not brought to your appointment, you will be personally charged for your appointment. If you need to cancel or change your appointment, please call our office at least 24 hours prior to your appointment. Please call us if you have any questions between now and your appointment time. Thank you and we look forward to meeting you soon. If you need help filling out this form, please dial 541.312.1145 and our staff will be happy to assist you. Please NOTE: All fields marked with an asterisk (*) MUST BE completed in order to proceed to the next page and to successfully submit this form. When you reach the bottom of each page click on "Next" to access the next page. Once all pages (there are 5 pages total) have been completed please click on the "Submit" button on the bottom of the final page. Thank you in advance for your help in ensuring an efficient check-in process for our patients and staff.PATIENT INFORMATIONPatient Name* Date of Birth* Month Day Year Gender Male Female Marital Status Married Single Widowed Divorced Phone*Address* City/State* Zip* Email* May we leave a telephone message?* Yes No Notes on preferred method of contact REFERRED BY: Were you referred to Dr. Villano by another provider?* Yes No If yes, who may we thank? Who is your primary care provider? PHARMACY: Please list your preferred pharmacy; include phone number if known GUARANTOR INFORMATIONGuarantor Name* Guarantor relationship to patient* Guarantor date of birth/SSN* Guarantor phone* Guarantor address* INSURANCE INFORMATION - PRIMARYInsurance company* Insurance group number* Policy number* Policyholder name* Policyholder date of birth* Policyholder relationship to patient* Policyholder employer Policyholder phone Policyholder address INSURANCE INFORMATION - SECONDARYInsurance company Insurance group number Policy number Policyholder name Policyholder date of birth Policyholder relationship to patient Policyholder employer Policyholder phone Policyholder address AUTHORIZATION FOR DISCLOSURE/RELEASE OF INFORMATIONI authorize medical treatment of the person named above and agree to pay all fees and charges for such treatment. I am signing this as a lifetime authorization for Michael E. Villano MD FACS to bill my insurance, Medicare, Medicaid and/or Medigap for these services; and to accept assignment of the benefits for Medicare, Medicaid, and/or Medigap. I authorize Michael E. Villano MD FACS to disclose complete information concerning medical finding(s) and treatment(s) of the undersigned, from the initial office visit until date of the conclusion of such treatment(s) to those individuals who, in Michael E. Villano MD FACS's determination, are required to receive such information for the purpose of medical treatment, medical quality assurance, peer review and, if applicable, to process the insurance claim for services rendered at Michael E. Villano MD FACS. I understand that I am responsible for any balance due for professional services in excess of the benefits provided by my policy. I agree to pay for services not covered by my insurance policy. I understand I am responsible for obtaining any prior authorizations required by my insurance policy. I understand that in the event of collection action, I am responsible for any legal fees incurred.Date* MM slash DD slash YYYY Signature*MEDICARE ASSIGNMENT (if applicable) I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party who may be responsible for paying for my treatment. (Section 112B of the Social Security Act and 31 U.S.C. 3801-3812 provides penalties for withholding information.) Regulations pertaining to Medicare assignment of benefits also apply.Date MM slash DD slash YYYY Signature REASON FOR VISITPlease explain the reason for your visit today. Describe your symptoms. When did symptoms start? What has the duration and/or progression of symptoms been like? What brings on your symptoms? Is there anything that relieves your symptoms? Does anything make symptoms worse? Include any other information that might be helpful in today's assessment.*MEDICAL HISTORYSURGERIES/YEAR PERFORMED Please list any surgeries and the year performed here. To add lines click on the "plus" circle at right.List MEDICAL DIAGNOSES, CHRONIC ILLNESSES Please list any medical diagnoses, chronic illness, or other medically relevant information here. To add lines click on the "plus" circle at right.List CURRENT MEDICATIONS Please list drugs you are currently taking here. Please include name of drug, dosage, and schedule (frequency). To add lines click on the "plus" circle at right.Drug Name/Dosage/Frequency ALLERGIES Do you have any drug allergies? Yes No List any medications that you have had a bad reaction to and describe how you react Do you have any tape, iodine, or latex allergies? Yes No RADIOLOGY TESTS Please list any radiological tests undergone in the last ten years (e.g., Head X-ray, Thryoid X-ray, CT/MRI Scans, Upper GI/Barium Swallow) HAVE YOU HAD ANY SERIOUS ILLNESSES OF THE FOLLOWING?Please check all that apply. Brain Nose Heart Blood Extremities Eyes Cancer Ears Lungs Abdomen Urinary Nervous Diabetes Reproduction Other Please elaborate on the above illnessesENT-specific Syptoms*Please check all that apply. Ringing R Ear Ringing L Ear Dizziness Pain in R Ear Pain in L Ear Drainage in R Ear Drainage in L Ear Hearing Loss R Ear Hearing Loss L Ear Nasal congestion Nasal drainage Facial pain External facial deformity Nasal bleeding Loud snoring Stop breathing while asleep Skin cancers Vomiting Nausea Recent weight loss Fevers/chills Night sweats Fatigue Shortness of breath Wheezing Hoarseness Throat clearing Swallowing pain Discomfort in throat Something in the throat Cough Heartburn/sour taste White balls on tonsils Large tonsils Itchy nose/ears/eyes Runny/watery eyes Sneezing fits Runny noses Scratchy throat Daytime sleepiness Blood in stool Neck/back pain Loss of sensation Paralysis of arm/leg Loss of speech Facial droop Chest pain/tightness Poor circulation Irregular heartbeat None, not listed Please elaborate on the above symptomsFamily History Hearing loss High blood pressure Cancer Alcoholism Psychiatric illness Stroke Diabetes Bleeding problems Heart attack Anesthesia reaction Have you had a bad reaction to local or general anesthesia? Yes No Please describe your reaction Have you had depression, anxiety, or other mental health issues requiring medical care? Yes No Please describe Do you have high blood pressure? Yes No Do you bleed easily from cuts or surgery? Yes No Are you prone to scarring? Yes No FEMALES Are you currently pregnant? Yes No Are you currently breast feeding? Yes No SOCIAL HISTORYHave you worked in a noisy environment or had exposure to loud noises? Yes No Please describe Do you currently smoke/vape/use nicotine products? Yes No Have you smoked/vaped/used nicotine products in the past? Yes No How long ago did you quit? Do you drink Alcohol? Yes No How much and how often? Do you currently use illicit drugs? Yes No Please specify your drug(s) of choice Do you have an advanced directive? I hereby consent to be examined and treated by Michael E. Villano, MD, and I certify that the above information is correct.Date* Month Day Year SIGNATURE OF PATIENT OR SPOUSE OR RESPONSIBLE PARTY* Patient name* Financial Policy We are committed to meeting your healthcare needs. Our goal is to keep your insurance or other financial arrangements as simple as possible. In order to accomplish this in a cost effective manner, we ask that you adhere to the following guidelines. Payment Options We accept Visa, MasterCard, personal checks and cash for insurance copays. Please be aware that we will add a $35 charge to your account for returned checks. We reserve the right to send all accounts with balances over 60 days old to an outside collection agency. All accounts sent to collections will be charged a $50 processing fee and any additional fees associated. You will be responsible for all reasonable collections and attorney costs incurred. Cancellations and No Show Cancellations within 24 hours of your scheduled appointment are subject to a $50 cancellation fee. Failure to show for your appointment without having cancelled more than 24 hours prior to the scheduled appointment time is subject to a $50 no-show fee. Insurance We offer benefit verification as a courtesy; however, it is your responsibility to obtain insurance coverage and benefits prior to your visit with us. As a patient, you will be responsible for any copays, additional testing, and services not covered by your insurance. If you do not have your insurance card, or we do not participate with your insurance plan, you can either reschedule your appointment or pay for your visit in full at the time services are rendered. We will supply you with the necessary information to submit your claim to your insurance company. Any balance left after your insurance has paid must be remitted within 30 days; if your account is not paid in full there will be a $50 rebilling fee applied to your account monthly. Uninsured Patients If you plan to pay privately for your services, please be advised that it is the policy of Cascade ENT to collect payment in full at the time of service. If you are unable to make payment in full at the time of service, your appointment will be rescheduled to a more convenient time. Motor Vehicle Accidents (MVA)/Third Party Liability We will require all claim details (claim#, contact info, billing address) at the time of your appointment; otherwise, we will require payment in full for services rendered for each patient being treated for an MVA/other accident-related injury. We will file claim(s) with motor vehicle or third-party insurers that you designate, provided we receive all necessary information with which to bill. If the claim(s) is (are) denied, or a protracted lawsuit is involved, the patient is responsible to pay the account balance in full. We will bill your private health insurer for balance left after your personal injury protection (PIP) is exhausted. Form Fees Forms and letters requested by our patients will be assessed a $30 administrative fee. This includes but is not limited to the following: Work Excuse, Disability Form, Workers Comp Form, Letters of Medical Necessity, Family Medical Leave Act Forms, MVA Forms.I acknowledge that I have received a copy of this financial policy. I agree to read this document and comply with the terms set forth for services rendered by Michael E. Villano MD LLC.Date* Month Day Year Financial Guarantor Signature* HIPAA ACKNOWLEDGMENT AND CONSENT I understand that Michael E Villano, MD (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 the 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 health-related 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; 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 or a summary of the most current version of This Practice's Notice of Privacy Practices in effect will be posted in waiting/reception area. I acknowledge that I have been informed that at times, new information about the practice may be promulgated via e-mail. I have the right to refuse receiving this information at any time by notifying the practice in writing. 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 have received a copy of the Notice of Privacy Practices.Date* Month Day Year Patient signature*Date MM slash DD slash YYYY Patient representativeDescription of Representative's Authority PATIENT REFERRALS RIGHTS Every patient has a choice when referred to a facility for a diagnostic test or health care treatment or service. As a patient you may receive the diagnostic test or health care treatment or service at a facility other than the one recommended by Dr. Villano. If you would like to be seen at a facility other than the facility recommended by Dr. Villano, you may request information regarding alternative facilities at the front desk. You may also speak to Dr. Villano. If you choose to have the diagnostic test, health care treatment or service at a facility different from the one recommended by Dr. Villano, you are responsible for determining the extent of coverage or the limitation on coverage for the diagnostic test, health care treatment or service at the chosen facility.List FacilityFirst ChoiceSecond ChoiceThird Choice Δ
