New patient packet

Victor E. Cohen, M.D.
Immunology
If you (or your child) now take(s) medication to help control asthma, you do not need to stop these before coming for the initial visit.
Antihistamines which are found in all allergy/sinus medications as well
as in most over the counter sleep medications should be avoided for at
least 7 days. Some stomach medications (Zantac, Tagamet, and Pepcid)
should also be discontinued for 7 days. If you are unsure about a
medication you are taking, please call our office.
You will spend approximately one hour or longer with me during
the initial visit. If the patient is a child, please bring him or her without
other children. I would like to be able to give the problem(s) at hand
my full and undivided attention.
Bring all medications that you are taking in their original containers
We request that you notify us at least 24 hours in advance if you will beunable to keep your appointment. Thank you.
NEW PATIENT INFORMATION SHEET
Patient Name:_____________________________________Birthdate:____________Sex: M FHome Address:_________________________________________________________________ Home Telephone: ( )_________________________Patient SS#:_________________________Marital Status: Occupation:____________________________________________________________________Employer: __________________________________Work Phone: (___)____________________Employer Address:_______________________________________________________________Race (optional): Asian Black Caucasian Hispanic Native American Other: ______ INSURANCE INFORMATION
Primary Insurance:_______________________________________________________________Insurance Address: __________________________________Phone #:(___)_________________Name of Insured: ________________________________Relationship to Patient:_____________Insured’s SS#:_____ - _____ - _____Insured’s Birthdate:____________ Group #:____________Insured’s Address: __________________________________Insured’s Phone #:_____________Insured’s Employer:_______________________________ Occupation:____________________Employer Address:____________________________________ Phone #:___________________ Secondary Insurance: ____________________________________________________________Insurance Address: __________________________________Phone #:(___)_________________Name of Insured: ____________________________Relationship to Patient:________________Insured’s SS#:_____ - _____ - _____Insured’s Birthdate:___________ Group #:_____________Insured’s Address:___________________________________ Insured’s Phone #:____________Insured’s Employer:_______________________________ Occupation:____________________Employer Address__ __________________________________ Phone #: ___________________ Emergency Contact:___________________Relationship:_______________Phone#:__________ How did you learn about Dr. Cohen? Another Patient Yellow Pages Internet another Dr.
Name of Dr. who referred you to us:_________________________________________________ OUR OFFICE WILL FILE INSURANCE CLAIMS AS A COURTESY TO YOU.
PLEASE REMEMBER YOU ARE RESPONSIBLE FOR ALL FEES REGARDLESS OF
WHETHER OR NOT YOU HAVE INSURANCE. YOUR INSURANCE CONTRACT IS
BETWEEN YOU AND YOUR INSURANCE COMPANY ALONE AND DOES NOT
INVOLVE THE DOCTOR. YOUR COPAY OR CO-INSURANCE AMOUNT IS DUE AT
THE TIME OF SERVICE. IF YOU HAVE NOT MET YOUR DEDUCTIBLE OR YOU
DO NOT HAVE INSURANCE, PAYMENT IN FULL IS DUE AT THE TIME OF
SERVICE.
I have been given a copy of the billing policy. I have read the billing policy and agree to
abide by the policy as stated.
______________________________________________________________________________
SIGNATURE OF RESPONSIBLE PARTY
Victor E. Cohen, M.D.
Immunology
OFFICE AND BILLING POLICIES
1. Co-pays, co-insurance and deductibles are due at the time of service. We accept Visa, MasterCard, Discover and Debit cards.
Any balance due must be paid in full unless special arrangements are made. We will be
happy to work with you on payment of large balances. There will be a $25.00 fee on any
returned check. If you are unclear about your balance, please contact the office so we can
assist you. It is your responsibility to contact your insurance if they have not paid, or if you
feel they have paid a claim incorrectly.
We bill most insurance plans. We will only bill a primary and secondary insurance. If no
response is received from your insurance, you will be responsible for paying the charges and
following up with your insurance company. Upon receipt of the Explanation Of Benefits
(EOB) from insurance we will make any adjustments required.
You must inform our office IMMEDIATELY of any change in your insurance coverage.
We do not know your insurance has changed unless you notify us. If notification is not
given prior to services being rendered, you will be responsible for paying any charges
incurred and for billing your own insurance. WE DO NOT BACK-BILL INSURANCE!
We have contractual obligations with insurance companies that require us to bill claims
within a certain amount of time. If the claims are not billed in that time frame the insurance
will not pay. WE MUST HAVE YOUR CURRENT INSURANCE INFORMATION ON
FILE AT ALL TIMES.
5. Accounts over 90 days past due and on which no payment has been made within the last 30 days may be sent to an outside agency for collection. You are responsible for paying all feesincurred by this office, the collection agency or attorneys during the collection process.
Collection accounts are reportable to credit agencies.
6. Refunds for amounts under $5.00 will be credited to your account for future services. 7. Prescription refills require a minimum of 24 hours notice. We ask that you call your pharmacy and have them fax us the refill request. Please understand that someprescription refills cannot be given without an office visit due to your medicalcondition. FMLA processing fees are $25.00 - $75.00 depending on format and are not billable toinsurance. Please allow 3 days to complete.
9. If you have any questions regarding these policies, please feel free to ask us for assistance.
I have read the above information and agree to abide by the policies as stated.
___________________________________ _________________________ Victor E. Cohen, M.D.
Immunology
ELIGIBILITY WAIVER
I, ___________________________________hereby certify that I am Name of patient, member, or guardian eligible participant under the _________________________plan as of ____________________. I understand that if I am not eligible I will be Month Day Year financially responsible for all services rendered to me by Dr. Cohen, and I agree to pay in full within 30 days of receiving a claim.
I authorize payment of medical benefits directly to Dr. Victor E. Cohen.
I authorize the release of medical records to any medical professional, hospital or medical care facility, insurance company or plan administrator for the purpose of evaluation, treatment or processing claims. This authorization is valid from the date signed for the duration of treatment.
____________________________ ____________ Victor E. Cohen, M.D.
Immunology
The following notice describes how your medical information may be used and
disclosed, and how you can get access to this information. Please review the
information carefully.
Your confidential healthcare information may be released to other healthcareprofessionals for the purpose of providing you with quality healthcare.
Your confidential healthcare information may be released to your insuranceprovider for the purpose of the practice receiving payment for providing you withneeded healthcare services.
Your confidential healthcare information may be released to public or lawenforcement officials in the event of an investigation in which you are a victim ofabuse, a crime or domestic violence.
Your confidential healthcare information may be released to other healthcareproviders in the event you need emergency care.
Your confidential healthcare information may be released to a public healthorganization or federal organization in the event of a communicable disease or toreport a defective device or untoward event to a biological product (food ormedication).
Your confidential healthcare information may not be released for any other
purpose than that which is identified in this notice.
Your confidential healthcare information may be released only after receivingwritten authorization from you. You may revoke your permission to releaseconfidential healthcare information at any time.
You may be contacted by the practice to remind you of any appointments,healthcare treatment options or other health services that may be of interest toyou.
You have the right to restrict the use of your confidential healthcare information.
However, the practice may chose to refuse your restriction if it is in conflict ofproviding you with quality healthcare or in the event of an emergency situation. You have the right to receive confidential communication about your healthstatus.
You have the right to review and photocopy any/all portions of your healthcareinformation.
You have the right to make changes to your healthcare information.
You have the right to know who has accessed your confidential healthcareinformation and for what purpose.
You have the right to possess a copy of this Privacy Notice upon request. The practice is required by law to protect the privacy of its patients. It will keepconfidential any and all patient healthcare information and will provide patientswith a list of duties or practices that protect confidential healthcare information.
The practice will abide by the terms of this notice. The practice reserves the rightto make changes to this notice and continue to maintain the confidentiality of allhealthcare information. Patients will receive a mailed copy of any changes to thisnotice within 60 days of making the changes. Victor E. Cohen, M.D.
Immunology
Patient Consent for the Use and Disclosure of Protected Health Information
With consent, Victor E. Cohen, M.D. may use and disclose protected health informationabout me to carry out treatment, payment, and healthcare operations. Please refer toVictor E. Cohen, MD’s ‘Notice of Privacy Practices’ for more complete description ofsuch uses and disclosures.
I have the right to review the Notice of Privacy Practices prior to signing this consent;Victor E. Cohen, M.D. reserves the right to revise its Notice of Privacy Practices atanytime. A revised Notice of Privacy practices may be obtained by forwarding a writtenrequest to Victor E. Cohen, M.D.’s Privacy Officer at 4445 S. Eastern Ave., Suite A, andLas Vegas, NV 89119.
With my consent, Victor E. Cohen, M.D.’s staff may call my home or other designatedlocation and leave a message on my voicemail or in person in reference to any items thatassist the practice in carrying out healthcare operations, such as appointment reminders,insurance items and any call pertaining to my clinical care, including laboratory resultsamong others.
With my consent, Victor E. Cohen, M.D.’s staff may mail to my home or otherdesignated location any items that assist the practice in carrying out healthcareoperations, such as appointment reminder cards, patient statements, insuranceinformation, and letters explaining your account.
However, the practice is not required to agree to my requested restrictions, but if it does,it is bound by this agreement. By signing this form, I am consenting to Victor E. Cohen,M.D.s’ use and disclosure of my Protected Health Information to carry out healthcareoperations. I may revoke my consent in writing except to the extent that the practice hasa ready made disclosure in reliance upon my prior consent. If I do not sign this consent,Victor E. Cohen, M.D. may decline to provide treatment to me.
Victor E. Cohen, M.D.
Immunology
THE FOLLOWING MEDICATIONS SHOULD BE DISCOUNTINUED
SEVEN DAYS PRIOR TO ALLERGY TESTING:
ANY COUGH/COLD PREPARATIONS
ANY ALLERGY MEDICATION (ANTIHISTAMINES)
OVER THE COUNTER SLEEPING MEDICATIONS : ALL OVER THE
COUNTER SLEEPING MEDICATIONS MUST BE DISCONTINUED
EXAMPLE ( TYLENOL PM,EXCEDRIN PM,NYTOL,SOMINEX).
ANTIHISTAMINES: (THIS IS ALIST OF MANY ANTIHISTAMINES)
THERE ARE MANY DIFFERENT NAMES FOR STORE BRAND
ANTIHISTAMINES.LOOK WITH CAUTION FOR THE WORD
ALLERGY OR SINUS ON THE BOX
ASTELIN NASAL SPRAY DRIXORAL
ACTIFED NALDECON
ALLEGRA PHENERGAN
ALLREST RYNATAN
ALLERX SINE-AID
ATARAX SINEQUAN
HYDROXYZINE SUDAFED PLUS
BENADRYL (plain sudafed is ok)
CHLORPHENIRAMINE TAVIST D
CLARITIN,CLARINEX TRIAMINIC
CONTAC TYLENOL SINUS
DIMETAPP (plain tylenol ok)
DRISTAN ZYRTEC
STOMACH MEDICATIONS:
AXID
PEPCID
TAGAMET
ZANTAC

Source: http://www.victorcohenmd.com/forms/new_patient_packet_english.pdf