Pulmonary Questionnaire

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    Facesheet

    Basic Information

    Medical Insurance Information

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    I authorize Montgomery Pulmonary Consultants.P.A to furnish information to insurance Carriers concerning my illness and treatments and I hereby assign the physician(s) all payment for medical services rendered to myself of my dependents.

    I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT COVERED BY INSURANCE.

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    MEDICAL RELEASE FORM

    Effective April 14,2003 (due to federal guidelines under HIPPA) we are now required to have a release form signed by the the patient before we can give out any medical or financial information to any person other than the patient.

    Please list below the names, relationship, and phone numbers for any authorized individual, (Spouse, family members, friends, caregivers, etc.) that we may discuss your medical or financial information with.

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    OR

    If you DO NOT want your medical or financial information discussed with anyone other than yourself,please sign here.

    The above is private and confidential and will be placed in your medical chart.The information on the form will remain valid until we are notified otherwise.

    Acknowledgement of Receipt of Notice of Privacy Practices
    (To be filed in patient's medical record)

    I have been presented with a copy of the Notice of Privacy Practices, detailing how my health information may be used and disclosed as permitted under federal and state law, and outlining my right regarding my health information.

    If patient/patient's representative refuses to sign acknowledgement, please document date and time notice was presented and sign below.

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    Montgomery Pulmonary Consultants, P.A.
    (Pulmonary Questionnaire)

    I.OCCUPATIONAL HISTORY:Please list entire working history. Start with present job and go backwards.

    I.PREVIOUS ILLNESSES:
    A.Have you ever been told that you have any of the following problems?

    1. Asthma?
    2. Emphysema?
    3. Chronic Bronchitis?
    4. Pneumonia?
    5. Tuberculosis?
    6. Pleurisy?
    7. Heart troubles of any kind?
    III.SYMPTOMS

    A.COUGH

    1. Do you usually cough first thing in the morning?
    2. Do you usually cough at other times during day or night?
    3. Do you usually cough first at the other times during day or night?
    4. Do you cough on most days for as much as three months per year?
    5. Do you cough during a particular season of the year?

    B.SPUTUM PRODUCTION

    1. Do you usually bring up phlegm, sputum, or mucous from your chest first thing in the morning?
    2. Do you bring up phlegm, sputum, or mucous from your chest as much as three months per year?
    3. How many years have you raised phlegm, sputum,or mucous from your chest?
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    C.WHEEZING

    1. Does your breath ever sound wheezy?
    2. At What age did Wheezing first occur?
    3. How frequently does wheezing occur?
    4. Is it worse at any particular day of the week? What day ?

    D.HEMOPTYSIS

      1.Have you ever coughed up blood from your chest?

    E.BREATHLESSNESS

    1. Do you get short of breath walking on level ground?
    2. Do you get short of breath walking up stairs?
    IV.SMOKING

    A.Check here if you have NEVER smoked

    B.CURRENT SMOKERS ONLY

    1. Do you smoke regularly?
    2. how old were you when you started smoking?
    3. For how many years have you smoked regularly?
    4. How many cigarettes do you smoke daily?
    5. How much pipe tobacco do you smoke per week?
    6. How many cigars do you smoke per day?
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    C. ALLERGIES(Medicines and any others)

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    Medicines Currently Taking(Name/Strength and Frequency)

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    Family History (List any serious medical problems; especially lung problems)

    List Your Medical Problems, Not involving the lungs

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    REVIEW OF SYSTEM / Non-Pulmonary

    Please Check Any Positive Findings

    General
    YES
    YES
    YES
    YES
    YES
    InsomniaExcessive daytime sleepines
    SKIN
    EAR,NOSE,THROAT
    YES
    YES
    YES
    YES
    CARDIOVASCULAR
    YES
    YES
    YES
    YES
    ABDOMINAL
    YES
    YES
    YES
    YES
    YES
    URINARY
    YES
    YES
    YES
    YES
    YES
    ENDOCRINE
    YES
    YES
    YES
    HEMATOLOGY
    YES
    YES
    MUSCULOSKELETAL
    YES
    YES
    NEUROLOGICAL
    YES
    YES
    YES
    YES
    YES
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    Medicare Part B

    Extended patient Signature Authorization

    TO BE COMPLETED BY PROVIDERS OF SERVICE

    TO BE COMPLETED BY PROVIDERS OF SERVICE - Directions for Payment Of Benefits And Release Of Medical Information

    STATEMENT FOR PAYMENT OF MEDICARE BENEFITS

    I request that payment of authorized Medicare benefits be made either to me or on my behalf to

    Dr. Saliski, Williams, Ensminger, Vyas, Noriega, Bansal, Gribben and Mohammed for any services or items furnished to me by the physician or supplier. I authorize any holder of medical information about me to release to the health care financing Administrator and its agents any information needed to determine these benefits or the benefits payable for related services.

    I request that payment of authorized Medicare benefit be made either to me or on my behalf to

    For any services furnished to me by the physician/supplier.

    I authorize any holder of medical information about me to release to (name of MEDIGAP insure)

    Any information needed to determine these benefits or the benefits payable for related services.

    IMPORTANT INFORMATION FOR PHYSICIANS

    In submitting claims under this procedure ,PHYSICIANS undertake.

    1. To complete and submit promptly the appropriate Medicare billing from for all services covered by the request for payment--even those in which the physician has not accepted assignment.
    2. To incorporate, by stamp or otherwise,information to the following effect on any bills send to Medicare patients."DO NOT USE THIS BILL FOR CLAIMING MEDICARE BENEFITS. A CLAIM HAS BEEN OR WILL BE SUMMITTED TO MEDICARE ON YOUR BEHALF."This requirement is necessary to prevent patients from submitting duplicate claims.
    3. To cancel the authorization on request by the patients.
    4. To make the patient signature files available for carrier inspection upon request.

    IMPORTANT INFORMATION FOR SUPPLIERS

    1. Only use this extended patient signature authorization for assigned claims.
    2. Renew the patient signature agreement if a new item is rented or purchased.
    3. place alongside the beneficiary's signature the following statement:"RESPONSIBILITY FOR OVERPAYMENT ON ASSIGNED CLAIMS ACCEPTED."

    DURABLE MEDICAL EQUIPMENT SUPPLIERS AGREEMENT

    NOTE:THE FOLLOWING STATEMENT MUST BE SIGNED BY THE DME SUPPLIER PRIOR TO AUTHORIZATION OF PAYMENT FOR RENTAL OF DURABLE MEDICAL EQUIPMENT IN ASSIGNMENT CASES.

    This supplier assumed unconditional responsibility for refunding of all overpayments for assigned claims for rental of durable medical equipment that may result from the failure of the Carrier to receive prompt notice of the return of,or the end of need for the rental of equipment ,or the death or institutionalization of the Beneficiary.

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