vascular associates of northern virginia - wordpress.com€¦ · alcohol: ☐ no ☐ yes qty per...

1760 Reston Parkway, Suite 306, Reston Virginia 20190 Voice: (571) 375-7174 Visit us on the web at: www.VascularAssociatesNOVA.com Fax: (571) 375-7177

(Revised 10/18)

Vascular Associates of Northern Virginia

Robert S. Podolsky, M.D., V. Cert., R.V.T., R.P.V.I.

Avisesh Sahgal, M.D., V. Cert., R.P.V.I.

Timely and considerate care of the arterial and venous systems

WELCOME TO OUR OFFICE

Please read the following information pertaining to your appointment.

Please take a few moments to fill out and sign all patient registration forms and bring the ORIGINALS of the following to your scheduled appointment.

➢ Patient Registration Form. ➢ Medical History Form ➢ Medication List Form

o Name, address and phone number of your local pharmacy. ➢ Office Financial Policy ➢ Release of Information Form ➢ Notice of Privacy Practice

WE WILL ALSO NEED:

1. ALL Insurance cards and VALID photo ID. Digital versions are not acceptable. You must have a physical card, or a printed copy of one, that can be scanned into your chart. 2. A list of all CURRENT Physicians or Specialists, their full names, along with their address, phone and fax numbers, so that we may forward information to them regarding your care here at Vascular Associates of Northern Virginia. 3. Any Vascular studies (i.e., MRA/MRI, CT/CTA or Doppler/Scan/Ultrasound) performed within the past six (6) months.

Please arrive thirty (30) minutes prior to your scheduled appointment time as it does take time to check you in and get your patient chart prepared. We try our best to be on time for you and all our patients. Failure to show

up thirty (30) minutes prior to your scheduled appointment time may result in you having to reschedule

your appointment.

If you have any further questions, do not hesitate to contact our office, Monday through Friday, 9 a.m. to 5 p.m. at (571) 375-7174. You may also refer to our website, www.VascularAssociatesNOVA.com for more information or to fill out, print and bring the patient registration forms with you at the time of your appointment. Thank you in advance for taking the time to complete your forms and prepare for your visit, so that we can better serve you at the time of your appointment.

Sincerely,


http://www.vascularassociatesnova.com/

1760 Reston Parkway, Suite 306, Reston, Virginia 20190 Voice: (571) 375-7174

Visit us on the web at: www.VascularAssociatesNOVA.com Fax: (571) 375-7177

(Revised 10/18)





PATIENT REGISTRATION

Do you have a Living Will? ☐Yes ☐No _____ Initials Patient Name: First M.I. Last Date of Birth: Financially Responsible Party:

☐Patient ☐Parent Home Address: City: State: Zip Code:

Home Phone: Cell Phone: Work Phone: Email Address:

Occupation: Employer: Employer Address:

Referring Physician: Personal Physician:

Race: Language: Ethnicity:

Marital Status: Spouse Name: Preferred Phone:

Person to Contact In Case Of Emergency: (Not Residing With You) Relation: Preferred Phone:

Primary Insurance Billing Information Secondary Insurance Billing Information

MUST BE COMPLETED MUST BE COMPLETED

PAYMENT POLICY

I acknowledge that all the provided information is true to the best of my knowledge.

I understand all necessary forms will be completed to help expedite insurance carrier payments, but that I am

financially responsible for any services not covered/paid by my insurance.

I agree to reimburse provider the fees of any collection agency, which may be based on a percentage at a maximum

of 28% of the debt, which fee shall be added at the time of placement with the collection agency, and all costs,

and expenses, including reasonable attorneys’ fees we incur in such collection efforts.

_______________________________________________ __________________

Signature of Patient/Responsible Party Date

Ins. Co. Name: ______________________________

I.D. #: _____________________________________

Group Name: _____________Group#: ___________

Subscriber Name: ____________________________

Subscribers Date of Birth: ______________________

Ins. Co. Name: ______________________________

I.D. #: _____________________________________

Group Name: _____________Group#: ___________

Subscriber Name: ____________________________

Subscribers Date of Birth: ______________________


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(Revised 10/18)





MEDICATIONS

Please List All Medications. ☐None Patient Name: ______________________________ Date of Birth: _______________ Date: _______________ Preferred Pharmacy: ________________________________ Telephone Number: _______________________ Address: _______________________________________________ Fax Number: _______________________

Medication Dose Directions Comments



(Revised 10/18)





Patient Name: ______________________________ Date of Birth: _______________ Date: _______________ Gender: ☐Male ☐Female Marital Status: ☐Single ☐Married ☐Widowed OCCUPATION: __Retired __Active: ________________________________________________ Medical Problems (for which you have seen a physician or have been treated): Heart Attack ☐ no ☐ yes Kidney Problems ☐ no ☐ yes Other Heart Problems: ________________ Breathing Problems ☐ no ☐ yes High Blood Pressure ☐ no ☐ yes COPD ☐ no ☐ yes

Stroke or Mini Stroke ☐ no ☐ yes Diabetes/sugar ☐ no ☐ yes Cancer ☐ no ☐ yes Blood Clots ☐ no ☐ yes Stomach/bowel ☐ no ☐ yes Others: ____________________________

Do you have any ALLERGIES or reactions to any medicines? ☐NO KNOWN DRUG ALLERGIES

List Past Surgery (with approximate date)

Do you now or have you ever: Smoked: ☐ no ☐ yes PPD ______ Date Stopped: ___________ Alcohol: ☐ no ☐ yes Qty per day ____ Date Stopped: ___________

Medication Reaction



(Revised 10/18)





Patient Name: ______________________________ Date of Birth: _______________ Date: _______________ Is there a history of any of the following in your immediate family (father, mother, brothers, sisters)?

Condition Mother Father Brother Sister Heart Attack

Other Heart Problems

High Blood Pressure

Stroke or Mini Stroke

Cancer

Varicose Veins

Kidney Problems

Breathing Problems/ COPD

Aneurysm: Location: _______________

Diabetes/sugar

Blood Clots

Do you CURRENTLY have any of the following? Yes No Yes No Shortness of breath Loss of vision

Chest pain or discomfort Severe headaches

Leg pain on walking Blackouts or falling

Foot pain at rest Abdominal pain

Skin ulcer or sores Back pain

Swelling of leg(s) Bruise easily

Varicose veins Bleeding problems

Episode of numbness, tingling, or weakness of arm or leg.

Episode when you could not speak, be understood when speaking, or understand others.


1760 Reston Parkway Voice: (571) 375-7174 Suite 306 Fax: (571) 375-7177 Reston, Virginia 20190 Visit us on the web at: www.VascularAssociatesNOVA.com

(Rev. 4/16)





OFFICE FINANCIAL POLICY

Welcome to our office. To help better serve you, please read and sign the following policy:

1. Payment in full is due at the time of service (copays, co-insurance, deductibles and outstanding account balances). It

is your responsibility to know if you have a co-pay and pay it at all office visits including any Vascular

Laboratory testing. We accept cash, checks, American Express, Discover, MasterCard or Visa.

2. All checks returned by the bank for insufficient funds will incur a $35.00 bank and administrative fee.

3. Your appointment time is reserved exclusively for you. When you No Show for an appointment, it takes time away

from someone else in need. No Showing or same day cancelling will result in a fee and possible discharge from the

practice.

➢ There is a $50 charge for a missed Office Visit without cancellation 24 hours prior to appointment.

➢ There is a $75 charge for a missed Vascular Laboratory study without cancellation 24 hours prior to

appointment.

➢ There is a charge of $300 to $500, depending on the surgery/procedure scheduled, for any missed

surgery/procedures without cancellation at least five (5) business days prior to appointment.

4. Patients who need referrals from their primary care physician are responsible for arriving with them. It is your

responsibility to obtain the referral. We are unable to obtain this referral for you. If your insurance requires a written

referral and you do not have it at the time of your appointment, you will NOT be seen, and you will be billed $50 for

a missed appointment.

5. As your provider, it is our responsibility to provide you with the best possible care. Please remember, your insurance

policy is between you and your insurance company, and not between your insurance company and us. For our

insurance patients:

➢ Please be aware that each insurance company has dozens of plans, all a little different. It is impossible for our

staff to have complete knowledge of each plan. We will do our best to quote your portion of the bill when you are

here, but as your insurance company tells us, they will not guarantee payment of their quoted amount until they

personally process your claim. In the event we receive more payment than expected, you will be refunded.

However, if there remains a balance due, you are responsible for all charges.

6. If you are having financial difficulties and wish to request a payment arrangement, you must do so in writing. Please

send a letter to the attention of the office manager and they will be in contact with you. Please note: No one at the

Loudoun Medical Group billing office has authorization to set up a payment arrangement. They may accept and

keep a credit card on file to make monthly payments, but this does not constitute a payment arrangement with this

office. Only Vascular Associates of Northern Virginia can set up a payment arrangement.

If there are any questions concerning you bill, please contact our billing office at (703) 443-6717.

Your signature indicates that you have read, understand, and agree to all the above policies. As a responsible party, your

signature indicates acceptance of the above policies and authorizations.

Signature__________________________________ Date__________________

Printed Name______________________________ Witness________________________________

(Witness only applicable if patient is not capable to sign)



(Revised 10/18)





NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”), I have certain rights to privacy regarding my protected health information. I understand this information can and will be used to:

➢ Conduct, plan, and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

➢ Obtain payment from third-party payers. ➢ Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you may restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree you are bound to abide by such restrictions.

Patient Name _______________________________________________

Signature __________________________________________________

Date ______________________________________________________

Witness _________________________________ (applicable only if patient is not capable of signing)

OFFICE USE ONLY

I attempted to obtain the patient’s signature in acknowledgement of this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:

Date: Initials: Reason:



(Revised 10/18)





RELEASE OF INFORMATION

I, the undersigned, authorize Vascular Associates of Northern Virginia, PC to speak with the persons listed below regarding my medical care and all billing issues. I understand that with my signature I am authorizing the release of written or oral communication by Vascular Associates of Northern Virginia, PC to the listed persons and thereby release Vascular Associates of Northern Virginia, PC and their staff from all legal responsibility that may arise from the act hereby authorized. ______________________________ _______________________ ________________________ Authorized Person Relationship to patient Phone Number ______________________________ _______________________ ________________________ Authorized Person Relationship to patient Phone Number ____________________________________ _____________________ Signature of Patient/Responsible Party Date

ASSIGNMENT OF BENEFITS

I, ________________________ (Please print your name), hereby authorize Vascular Associates of Northern Virginia, PC to apply benefits for covered services rendered by Vascular Associates of Northern Virginia, PC, and to request that payment from Medicare, Medicaid, Blue Cross/Blue Shield and or __________________________________________________. I certify that the information I have reported with regard to my insurance is correct and further authorize the release of any necessary information, including medical information for this or any related claim to Medicare, Medicaid, Blue Cross/Blue Shield and or______________________________________________(other insurance listed above). I request that payment of authorized Medigap benefits be made on my behalf to the above name provider for any services provided to me by that physician/supplier. I authorize any holder of medical information about me to release to____________________________________ (name of Medigap carrier) any information needed to determine these benefits payable for related services. I permit a copy of this authorization to be used in place of any previously signed document. This authorization may be revoked by me at any time in writing. _______________________________________ ____________________ Subscriber or Policy Holder Signature Date



(Revised 10/18)





CARE TEAM

Patient Name: ______________________________ Date of Birth: _______________ Date: _______________

Please provide name, address and phone number.

Referring Physician: _________________________________________________________________________ Primary Care Physician/Internist: ______________________________________________________________ Cardiologist: _______________________________________________________________________________ Podiatrist: _________________________________________________________________________________ Nephrologist: ______________________________________________________________________________ Dialysis Center: ____________________________________________________________________________ Dialysis Day: __________________________________ Dialysis Shift: ________________________________ Other Physician: ____________________________________________________________________________ Other Physician: ____________________________________________________________________________ Other Physician: ____________________________________________________________________________


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