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M F Estado Nombre del padre o guardian

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Central Coast Otolaryngology
116 S. Palisade, Suite 206, Santa Maria, CA 93454 Ph: (805) 614-9250 Fax: (805) 614-9260
**Please use black/blue pen only
Today’s date/Fecha de hoy:
/ /
Age/Edad
Referring Physician/Doctor Regular
Patient’s Name/Nombre del paciente
Sex/Sexo
M
F
Birthdate/Nacimiento
/ /
Marital Status
Single
Married
Widowed
Divorced
Address/Direccion
State/
Estado
Home Phone /Telefono
If child, parent’s or legal guardian’s name/
Nombre del padre o guardian
Place of Employment
Work Number
Patient’s Social Security #/Seguro de Paciente
E-Mail Address
Cell Number
Emergency Contact/Contacto en caso de emergencia
Relationship to patient
Contact Number
Race/Raza:
Ethnicity/Etnicidad:
Language Preferred/Idioma Preferido:
Primary Insurance name/Nombre de aseguranza
primaria:
Subscriber’s Social Security Number
Subscriber’s name/Nombre de la persona en el seguro:
Subscriber’s Birthdate/Nacimiento de la persona en el seguro
/ /
If different, list person financially responsible if other
than patient/Persona responsable de cuenta:
Address/Direccion
Phone Number
Secondary Insurance name/Nombre de segunda
aseguranza
Subscriber’s Social Security Number
Secondary Subscriber’s name/Nombre de la persona
en el seguro:
Subscriber’s Birthdate/Nacimiento de la persona en el seguro
/ /
I certify the information above is true to the best of my knowledge. I authorize this office to release any
information necessary to expedite insurance claims. I understand that insurance coverage is not a
guarantee of payment and I may be responsible for any or all charges.
Pa
tient/Parent/Guardian Signature/
______________________ Date/Fecha_____________________
Firma de paciente/padre/guardian
Central Coast Otolaryngology
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signature
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Central Coast Otolaryngology
116 S. Palisade, Suite 206, Santa Maria, CA 93454 Ph: (805) 614-9250 Fax: (805) 614-9260
PATIENT NAME:_____________________________________DATE OF BIRTH:_________________________
Please check all that apply/Favor de marcar lo apropriado
Medical History/Historia Medica:
Heart disease-please specify:
________________________________
Diabetes
Sleep apnea/Apnea del
Sueño
Hypertension/Alta presion
Cancer
Insomnia
Vertigo/Mareos
Narcolepsy
Congestive heart failure/insuficiencia cardíaca
congestiva
Hepatitis
Tuberculosis
Arthritis-please specify:
_________________________________
Fibromyalgia
Sinusitis
Nosebleeds/ hemorragias nasales
Hearing loss/Sordera
Allergic rhinitis
GERD/heartburn/Acidez
Meniere’s disease
COPD
Bipolar disorder
High Cholesterol/Alto
colesterol
Depression
Seizure disorder
Schizophrenia
Parkinson’s Disease
Alzheimer’s Disease
Psychiatric problems-please
specify ________________
Kidney disease/Problemas
de riñones
List Other medical issues/Otros problemas médicos __________________________________________________________
_________________________________________________________________________________________________
Surgical History/Operaciones:
Appendectomy/Apendiz
Gastric Bypass
Gall Bladder/Vesicula
Heart bypass/Corazon
Tonsillectomy/Anginas
Ear tubes/Tubitos
Hysterectomy/matriz
Thyroidectomy/Tiroides
Nasal septoplasty/Nariz
Tympanoplasty
Sinus
Neck/Cuello
List Other Surgeries/Otras Operaciones:
______________________________________________________________________________________________
Social History/Historia Social:
Non-Smoker/No Fumo
Non
-Drinker/ No Tomo
Smoker/
Fuma
Packs a day?/Paquetes al dia?
_____________
How many years/ Por cuantos
años?________________
Quit_________
Alcohol
How often/Cuanto?
________
Street Drugs______________________
Family History/Historia
Familiar:
Obstructive sleep
apnea/apnea obstructiva
Bleeding/Hemorragias
Hypertension/Alta
Presion
Heart disease/Problemas del
corazon
Hearing loss/Sordera
Cancer
Diabetes
List Other/Otros Problemas:
Allergies to medications/Alergias a medicamentos:
None/Ninguno
Sulfonamides/Sulfa
Penicillin/Penicilina
Aspirin, ibuprofen, naproxen
Cephalosporins
Others/otros: _____________________
Latex
Anesthesia/anestesia
Not taking any medications/No tomo medicamentos
List Medications/Anote Medicamentos: Preferred Pharmacy:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_____________________________________________________________________________________________
Central Coast Otolaryngology
Central Coast Otolaryngology
116 S. Palisade, Suite 206, Santa Maria, CA 93454 Ph: (805) 614-9250 Fax: (805) 614-9260
P
atient privacy Rights
Derechos de Privasidad como Paciente
The medical practice of Central Coast Otolaryngology (Richard P. Wikholm, MD, Zachary P. VandeGriend, M.D.) and
associates have implemented policies to protect the privacy of your medical records. The following is a description of
how we manage your individual medical information. / La práctica de la medicina de la Costa Central
Otorrinolaringología (Richard P. Wikholm, MD, Zachary P. VandeGriend, M.D.) y los asociados han implementado
políticas para proteger la privacidad de sus registros médicos. La siguiente es una descripción de cómo manejar su
información médica personal.
A
n electronic record of your health care is constructed at each encounter. This record may include your symptoms,
examination, test results, treatment plan, outside records, and other medical information. . Safeguards are taken to prevent
the unintended disclosure of your health care information during creation, utilization, storage, and destruction. Anything
that identifies a patient with his/her individual medical care is protected. Un registro escrito o electrónico de su cuidado
de salud se construye en cada encuentro.. Este registro puede incluir sus síntomas, examen, resultados de la prueba, plan
de tratamiento, registros fuera y otra información médica.. Las salvaguardias se toman para evitar la divulgación
accidental de su información médica durante la creación, utilización, almacenamiento y destrucción. Algo que identifica
a un paciente con su atención médica individual está protegido.
B
y law, your medical information may be shared (without your authorization) for:
Por ley, su información médica puede ser compartida (sin su autorizacion) para:
Treatment/Tratamiento- To facilitate your care, we may share information with consulting physicians, healthcare
entities, public health and legal entities, and on-call physicians. For example, we send a consulting physician relevant
chart notes. En casos de referirlo a otro medico para mejor tratamiento, nosotros mandaremos su informacion a la
oficina endicada.
Payment/Pago- To obtain payment from third parties, we will provide requested information to insurers. For example,
your insurance company may request chart notes before payment. Mandaremos informacion suya a su compania de
aseguranza para obtener pago.
H
ealthcare Operations- We may supply medical information for the purpose of quality control, business activities, and
other health care operations. For example, we may need to call your home phone number to remind you of an
appointment. Podemos suministrar información médica para fines de control de calidad, actividades comerciales y otras
operaciones de cuidados de salud. Por ejemplo, es posible que tengamos que llamar a su número de teléfono para
recordarle las citas.
A
ny other disclosures of your medical record will require your written or expressed authorization. This includes
disclosures to non-dependent family members. All disclosures of your record requiring authorization will be documented.
Cualquier otra in
formación de su historial médico, requerirán la autorización expresa o por escrito. Esto incluye
declaraciones a los no miembros de la familia dependientes. Todas las divulgaciones de su expediente que requieren
autorización serán documentadas.
P
lease list any person or persons to whom you would like us to disclose any information to (i.e.: family member or
spouse) /personas cual usted autoriza abtener informacion del paciente (ejemplo: un familiar/persona aparte del
paciente o padres)
____
______________________________ ________________________
Name/nombre Relationship/relacion
____
______________________________ __________________________
Name/nombre Relationship/relacion
Central Coast Otolaryngology
Central Coast Otolaryngology
116 S. Palisade, Suite 206, Santa Maria, CA 93454 Ph: (805) 614-9250 Fax: (805) 614-9260
You have certain rights regarding your individual record, including the right:
Tienen ciertos derechos en relación con su registro individual, incluido el derecho de:
1) To request restrictions and amendments regarding your record. Your request must be in
writing, specific, and time sensitive. Solicitar restricciones y enmiendas en relación con
su registro. Su solicitud debe ser por escrito, específicas y sensibles al tiempo. No vamos
a aceptar o negar su solicitud por escrito.
2) To file written complaints concerning your record to our office manager. Presentar
denuncias escritas sobre su registro a nuestro director de oficina
3) To revoke in writing, any prior disclosure authorizations at any time. Revocar por escrito
cualquier autorización previa en cualquier momento.
Some of the specific actions we have taken to protect your privacy include/ Algunas de las
acciones específicas que hemos tomado para proteger su privacidad incluyen:
1) All employees with access to your medical record are trained to protect your privacy. Privacy
training includes protection both in the office and in the community. Todos los empleados
han sido entrenados a protejer su informacion y privacidad.
2) Contracted and business associates with access to your medical record have been instructed
regarding the confidential handling of your record, and have signed agreements to protect
your privacy. Companías con cual tenemos negocios han sido ordenadas a manejar con
delicadés su información personal.
3) Your medical record and demographic information is never knowingly sold or otherwise
released for non-medical or commercial purposes. Su información nunca sera vendida o dada
por razones no medicas.
NON-COVERED BENEFITS: Professional fees not covered by insurance-due at time of
service. Please allow 48 hour turn-around time
• Forms to be filled out; (i.e. disability) …………………………………….………….$20.00
• Written letters; (i.e. jury duty letter, CPAP travel letter) …………………………..$20.00
• Request for records-greater than 5 pages…………………………………………….$20.00
Your signature is acknowledgement that our privacy policy has been made available to you. Su
firma es el reconocimiento de que nuestras reglas de privacidad ha sido puesto a su disposición
Signature/Firma Date/Fecha
Central Coast Otolaryngology
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signature
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Central Coast Otolaryngology
116 S. Palisade, Suite 206, Santa Maria, CA 93454 Ph: (805) 614-9250 Fax: (805) 614-9260
OFFICE APPOINTMENT & FINANCIAL RESPONSIBILITY POLICY
Reglas y Responsibilidades de Nuestra Oficina
Appointments/Citas
1. We value the time we have set aside to see and treat you as a patient. If you are not able to keep an
appointment, we would appreciate a 24-hour notice. We have an automated system in place to call
and confirm all appointments, however it is the patient’s responsibility to remember his/her own
appointment. Si usted necesita cancelar su cita, favor de hablar 24 horas antes. Tenemos un sistema
automatizado en lugar para llamar y confirmar todas las citas, sin embargo, es la responsabilidad del
paciente para recordar su propia cita.
2. As a courtesy, our staff mails out all new patient paperwork prior to your appointment. This
minimizes any unnecessary waiting time. Incomplete paperwork will result in an automatic
rescheduling of that day’s visit.
Como cortesía, nuestro personal envia por correo todo el papeleo de nuevo paciente antes de su cita.
De este modo, se minimiza el tiempo de espera innecesarios. Documentación incompleta provocará
una cancelacion automática.
3. If you are late for your appointment (>15 minutes), we will do our best to accommodate you.
However, on certain days it may be necessary to reschedule your appointment. Si usted llega mas de
quince minutos tarde nosotros tenemos el derecho de cancelar su cita y cambiarsela para otro dia.
4. We strive to minimize any wait time; however, emergencies do occur and will take priority over a
sch
eduled visit. Tenemos dias cuando suseden emergencias, en esos casos las emergencias tendran
prioridad sobre citas ya fijadas
.
Financial Responsibility/Responsibilidad Finaciera
1) It is the patient’s responsibility to pay any deductibles, co-insurance, co-payments, or any portion of
the charges as specified by their insurance. Si tiene un copago favor de pargarlo al tiempo de su cita.
2) Self-pay/cash patients are expected to pay for services in FULL at the time of the visit. Se espera que
los pacientes de pago efectivo pagen los servicios en su totalidad en el momento de la visita.
3) If we do not participate in your insurance plan, payment in full is expected from you at the time of
your visit. Si no participamos en su plan de seguro, el pago en su totalidad se espera de usted en el
momento de su visita.
4) Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits. Los
salos de los pacientes se facturan inmediatamente al recibimiento de la explicación del plan de seguro
de los beneficios.
5) Any balance outstanding longer than 90 days will be forwarded to a collection agency. Cualquier
saldo pendiente más de 90 días se enviará a una agencia de cobranza.
6) We accept cash, checks, Visa, MasterCard, Discover, American Express credit and debit. Aceptamos
dinero en efectivo, cheques, Visa, MasterCard, Discover, American Express y débit
o.
7) A $20 fee will be charged for any checks returned for insufficient funds. Se cobrará una tarifa de $20
par
a cualquier cheques devueltos por falta de fondos.
I
have read and understand this office policy and agree to comply and accept the responsibility for any
payment that becomes due as outlined previously. He leido las reglas y reponsibilidades y estoy de acuerdo
con ellas.
Signature Date
Central Coast Otolaryngology
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M F Estado Nombre del padre o guardian

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Completed 16 August 2021

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