Skilled nursing care advance beneficiary notice

PATIENT REGISTRATION AND
PROTECTED HEALTH INFORMATION PREFERENCES
Have you applied for or are you eligible for Medicare? Other than you, your insurance company and healthcare providers involved in your care, whom can we talk with Relationship to Patient: □ Self □ Spouse □ Child Relationship to Patient: □ Self □ Spouse □ Child PLEASE READ CAREFULLY: I hereby authorize release of any information obtained in the course of my registration, interview,
examination and treatment necessary to file a claim with my insurance carrier. If my insurance company does not offer
bariatric benefits, I understand that Weight Loss Surgical Center may attempt to bill to my insurance company. I
authorize payment directly to the provider for services provided. I understand I am financially responsible for charges not covered by my insurance including but not limited to medical services deemed routine, elective, or not medically necessary by my insurance company and/or any co-pays, deductibles, co-insurance amounts or non-covered items specified by my insurance company. In the event that my account is placed in the hands of a collection agency or attorney for collection, I agree to pay all costs and expenses related to the collection thereof. A copy of this signature is valid as the original. PATIENT HISTORY

□ I HAVE ATTENDED A LIVE OR ON-LINE GASTRIC BAND SEMINAR

PRIMARY CARE DOCTOR
(Please fill in all blanks.)
Name:

SPECIALIST LIST
(Please list all doctors who have assisted you with weight loss or are involved in your medical care.)
Doctor:
PATIENT HISTORY
DIETING HISTORY
(Please check the ones you have tried.)

Diets/Programs
□ Advocare
Over-the-Counter Meds
Prescription Meds
Exercise
PATIENT HISTORY
MEDICAL HISTORY

Obesity Co-Morbidities or Signs & Symptoms
(The medical conditions listed below are associated with obesity, check the ones you have.)



Additional Medical History
(Please check all medical conditions you have or have had in the past.) PATIENT HISTORY

SURGICAL HISTORY
(Please list all surgical procedures you have had done in the past.)
Surgery Year

Any surgical complications/infections?
FAMILY MEDICAL HISTORY
(Please check all medical conditions your blood relatives have, indicate relationship.)

SOCIAL HISTORY
(Please answer all the questions below.)
Occupation:
Marital Status: Single Married Widowed Divorced Do you or did you drink excessive alcohol? Do you use or have you used recreational drugs? Y
CURRENT MEDICATIONS
(Please list all current medications with dosages, or provide a list.)

DRUG ALLERGIES/REACTIONS:
PATIENT HISTORY

REVIEW OF SYSTEMS
(Please check symptoms that you have had or may be experiencing.)

General/Constitution
Cardiovascular
Genitourinary
Skin/Breast
Respiratory
Neurological
Ear, Nose & Throat
Hematologic
Gastrointestinal
Endocrine
Psychiatric
Prior Bariatric
I have completed this form to the best of my ability. I understand that I will be required to meet with a Physician’s Assistant or Nurse Practitioner, and a surgeon prior to surgery. This information will be used to determine if I am a surgical candidate and to assist in the pre-determination of my surgery through my insurance company.

SIGNATURE:

Source: http://www.moreoflife.com/docs/patient-forms.pdf