New Patient Registration

Name*

First Middle Last

Sex*

Male
Female

Date of Birth*

Social Security Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Number*

Cell Number*

Work Number

Email*

Emergency Contact*

First Last

Emergency Contact Phone*

Emergency Contact Relationship*

Primary Insurance

Insurance*

Does This Insurance Require Pre-Authorization?*

Yes
No

Date Effective*

Group #*

Insurance ID*

Policy Holder*

First Last

Date of Birth*

Social Security Number*

Insurance Claim Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Insurance Phone Number*

Secondary Insurance

Do You Have Secondary Insurance?

Yes
No

Insurance

Does This Insurance Require Pre-Authorization?

Yes
No

Date Effective

Group #

Insurance ID

Policy Holder

First Last

Date of Birth*

Social Security Number

Insurance Claim Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Insurance Phone Number

Privacy and Security Release

As a covered of the Health Insurance Portability and Accountability Act (HIPPA) Texas Kidney Institute, PA, and its business associates are protecting the privacy and security of your medical information. As such we do not release any information without your approval. This includes, but is not limited to medical and financial information. Please list any persons below, whom you are giving permission to have Texas Kidney Institute, PA, or its business associates, release information in regards to your care or billing.

Person's Name

First Last

Relationship

Release

Medical
Financial

Medical History

Do You Have Other Physicians?

Yes
No

Name

First Last

Specialty

Phone Number

Fax Number

Name of Pharmacy

Phone Number

Do You Have A History Of Tobacco Use?*

Yes
No

Packs Per Day*

For How Many Years?*

Do You Have A History Of Alcohol Use?*

Yes
No

Quantity*

Frequency*

Do You Have A History Of Illicit Drug Use?*

Yes
No

Quantity*

Frequency*

Do You Have Advanced Directives?*

Advance directives are legal documents that allow you to spell out your decisions about end-of-life care ahead of time. They give you a way to tell your wishes to family, friends, and health care professionals and to avoid confusion later on.

Yes
No

Typical Breakfast, Lunch, Dinner, Snacks, and Beverages

Type of Exercise

Family History - Mother

List important medical problems of your mother.

Family History - Father

List important medical problems of your mother.

Any Other Special Medical Information

Mother

Alive
Deceased

Age

Deceased At Age

Cause Of Death

Father

Alive
Deceased

Age

Deceased At Age

Cause Of Death

Sister

Alive
Deceased

Age

Deceased At Age

Cause(s) Of Death

Other Sister (If Applicable)

Alive
Deceased

Age

Deceased At Age

Cause(s) Of Death

Brother

Alive
Deceased

Age

Deceased At Age

Cause Of Death

Other Brother (If Applicable)

Alive
Deceased

Age

Deceased At Age

Cause Of Death

Other Siblings

If you have more siblings, please provide their information here as well.

Drug Sensitivies/Allergies

Please describe below if you have any sensitivities or allergies to certain medications.

Have You Ever Been Told You Had One of the Following?

Please check all the boxes that apply to you if you have been told you had one of the following.

If You Answered Yes To Any of the Above, Please Describe

Disease or Disorder of the Blood? (Describe)

Any Physical Defect or Deformity? (Describe)

Any Vision or Hearing Disorders? (Describe)

Any Life-Threatening Conditions? (Describe)

Have You Been Treated By A Physician or Been Disabled or Hospitalized During the Last Year? (Describe)

Have You Had or Been Advised to Have A Surgical Operation Within the Last Five Years? (Describe)

Financial Policy and Agreement

In order for our medical staff to be able to deliver the quality of care that you are accustomed to, we have established our financial policies. The following is a list of guidelines that are necessary in order to continue to provide high quality care and make your visit as pleasant as possible

Please present your insurance card at each visit. It is your responsibility to provide us with the correct information to bill your insurance. If you have a change of address, telephone number, or employer, please notify the office
We will collect your co-pay, deductible, or charge for non-covered services at the time of your visit. If you have balance after an insurance payment from a previous service, we will also ask for that payment. We accept cash, check, Visa and MC
If we do not participate with your insurance company, you will be expected to make payment in full at the time the service is rendered.
If your insurance denies our charges or does not pay us in a timely manner, or if your account becomes delinquent, we reserve the right to refer your account to a collection agency and to be reported to one or more credit bureau(s). If your account is referred to a collection agency, you will be billed the amount you owe plus 30%
HMO-PPO PATEINTS: If we participate with your plan, we will bill your insurance for you. Your co-payment will be collected at the time of service – no exceptions. If your plan requires you to have an authorization to see a specialist, you will need to obtain that prior to seeing the specialist. No retroactive referrals will be given. If we do participate with your plan, we will verify your out-of network benefits, file your charges, and will expect payment of your portion of the charges at the time of service
SELF-PAY PATIENTS: Patients with no insurance are expected to pay at the time of service. If you will not be able to pay in full; you must contact our practice administrator prior to seeing the physician to make payment arrangements
No Show or missed appointments: We understand that there may be times when you an unable to keep your appointment, but we ask the courtesy of a phone call to cancel or re-schedule your appointment. If two(2) appointments are missed without cancellation, you will be charged a $25.00 fee.
Your insurance is a contract between you, your employer and the insurance company. WE ARE NOT A PARTY TO THAT CONTRACT. It is very important that you understand the provisions of your policy. We cannot guarantee payment of all claims. If your insurance company pays only a portion of the bill or rejects your claim, any contact or explanation should be made to you, their policy holder. Reduction or rejection by your insurance does not relieve you of your financial obligations. You will be responsible for the balance due.
Non-covered Medicare/Medicaid Services and HMO/PPO/Private Insurance: Insurance have certain outpatient services/procedures that are excluded from coverage, included but not limited to those routine diagnostic workups, labs or routine examinations. If your insurance does not pay/cover all the charges, the charges incurred during treatment will be your financial obligation.

Remember, whether you do or do not have insurance, you are ultimately financially responsible for payment of your charges. If you have any questions regarding our policy and this agreement, please contact our practice administrator at (214) 396 4950.

HIPAA Privacy Policy

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED BY TEXAS KIDNEY INSTITUTE, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

UNDERSTANDING YOUR PROTECTED HEALTH INFORMATION (PHI):

Understanding what is in your health record and how your health information is used will help you to ensure its accuracy, allow you to better understand who, what, when, where and why others may access your health information, and assist you in making more informed decisions when authorizing disclosure to others. When you visit us, we keep a record of your symptoms, examination, test results, diagnoses, treatment plan, and other medical information. We also may obtain health records from other providers. In using and disclosing this protected health information (PHI), it is our objective to follow the Privacy Standards of the federal HealthInsurance Portability and Accountability Act (HIPAA), 45 CFR Part 464. The law does not require your specific authorization for us to use and disclose PHI for treatment, payment, operations and other specific purposes explained below in PHI Disclosure. This includes contacting you for appointment reminders and follow-up care. All other uses and disclosures require your specific authorization.

YOUR HEALTH INFORMATION RIGHTS ALLOW YOU TO:

Request a restriction on the uses and disclosures of PHI as described in this notice, although we are not required to agree to the restriction you request. You should address your request in writing to the Privacy Officer. We will notify you within 30 days if we cannot agree to the restriction.
Obtain a paper copy of this Notice and upon written request, inspect and obtain a copy of your health record for a fee of $.60 per page and the actual cost of postage per NRS 629.061, except that you are not entitled to access, or to obtain a copy of, psychotherapy notes and information compiled for legal proceedings.
Amend your health record by submitting a written request with the reasons supporting the request to the Privacy Officer. In most cases, we will respond within 30 days. We are not required to agree to the requested amendment.
Obtain an accounting of disclosures of your health information, except that we are not required to account for disclosures for treatment, payment, operations, or pursuant to authorization, among other exceptions.
Request in writing to the Privacy Officer that we communicate with you by a specific method and at a specific location. We will typically communicate with you in person; or by letter, e-mail, fax, and/or telephone.
Revoke an authorization to use or disclose PHI at any time except where action has already been taken.

OUR RESPONSIBILITIES AS REQUIRED BY LAW:

Maintain the privacy of PHI and provide you with notice of our legal duties and privacy practices with respect to PHI.
Abide by the terms of the notice currently in effect. We have the right to change our notice of privacy practices and we will apply the change to your entire PHI, including information obtained prior to the change.
Post notice of any changes to our Privacy Policy in our office and make a copy available to you upon request.
Use or disclose your PHI only with your authorization except as described in this notice.
Follow the more stringent law in any circumstance where other state or federal law may further restrict the disclosure of your PHI.

FOR MORE INFORMATION OR TO REPORT A PROBLEM, CONTACT THE PRIVACY OFFICER AT:

Purnima Kumar
214-396-4950

If you feel your rights have been violated, you may file a complaint in writing with the Privacy Officer. If you are not satisfied with the resolution of the complaint, you may also file a complaint with the Secretary of Health and Human Services. Filing a complaint will not result in retaliation.

PHI DISCLOSURE: We may use or disclose your PHI for treatment, payment and operations, and for purposes described below:

TREATMENT: We will use and exchange information obtained by a physician, nurse practitioner, nurse or other medical professionals in our office to determine your best course of treatment. The information obtained from you or from other providers will become part of your medical records. We may also disclose your PHI to other outside treating medical professionals and staff as deemed necessary for your care. For example, we may disclose your PHI to an outside doctor for referral. We will also provide your health care providers with copies of various reports to assist them in your treatment.

PAYMENT: We may send a bill to you or to your insurance carrier. Also, our billing office may receive PHI as necessary to send a bill to you or to your insurance carrier. The information on or accompanying the bill may include information that identifies you, as well as that portion of your PHI necessary to obtain payment.

HEALTH CARE OPERATIONS: Members of the medical staff, a Risk or Quality Improvement team, or similar internal personnel may use your information to assess the care and outcome of your care in an effort to improve the quality of the healthcare and service we provide or for educational purposes. For example, an internal review team may review your medical records to determine the appropriateness of care.

OTHER USES AND DISCLOSURES NOT REQUIRING AUTHORIZATION:

Business Associates: There are some services provided to our organization through contracts with business associates, such as laboratory, radiology services and billing services. We may disclose your health information to our business associates so that they can perform these services. We require the business associates to safeguard your information to our standards.
Notification: We may disclose limited health information to friends or family members identified by you as being involved in your care or assisting you in payment. We may also notify a family member, or another person responsible for your care, about your location and general condition.
Legally Required Disclosures & Public Health: We may disclose PHI as required by law, or in a variety of circumstances authorized by federal or state law. For example, we may disclose PHI to government officials to avert a serious threat to health or safety or for public health purposes, such as to prevent or control communicable disease (which may include notifying individuals that may have been exposed to the disease, although in such circumstance you will not be personally identified), federal or state health oversight agencies, child abuse or neglect, domestic violence, to an employer to evaluate work related injuries, and to public officials to report births and deaths.
Law Enforcement & Subpoenas: We may disclose PHI to law enforcement such as limited information for identification and location purposes, or information regarding suspected victims of crime, including crimes committed on our premises. We may also disclose PHI to others as required by court or administrative order, or in response to a valid summons or subpoena.
Information Regarding Decedents: We may disclose health information regarding a deceased person to: 1) coroners and medical examiners to identify cause of death or other duties, 2) funeral directors for their required duties and 3) to procurement organizations for purposes of organ and tissue donation.
Research: We may also disclose PHI where the disclosure is solely for the purpose of designing a study, or where the disclosure concerns decedents, or a privacy board has determined that obtaining authorization is not feasible and protocols are in place to ensure the privacy of your health information. In all other situations, we may only disclose PHI for research purposes with your authorization.

DISCLOSURES REQUIRING AUTHORIZATION: The release of health information to other treating professionals other than your health care providers will be made with written authorization from the patient, which you have the right to revoke at any time, except to the extent we have already relied upon the authorization or in the event of an emergency.

ACKNOWLEDGEMENT OF RECEIPT: Federal law requires that we seek your acknowledgment of receipt of this Notice of Privacy Practices. Please sign below.

I acknowledge that I have received this Notice of Privacy Practices with an effective date of March 15, 2012, and that I understand that if I have any questions regarding this Notice, I may contact the Privacy Officer.

Consent For Treatment

I understand that I may have a medical condition that could possibly require diagnosis and treatment. I do hereby voluntarily consent to such treatment, services, and procedures that may be recommended under the general and specific instructions of the physicians of Texas Kidney Institute, his/her assistants, or his/her designee.

I acknowledge that the practice of medicine is not an exact science and that the physicians of Texas Kidney Institute have made no guarantees to me as to the result of treatments or examination.

Texas Kidney Institute recognizes the importance and significance of maintaining confidentiality of information retarding a patient’s medical condition. We also want to provide our patients timely communication as to laboratory/diagnostic test results, etc. We understand that because of the patient’s schedules and our office schedule this may sometimes be difficult. Texas Kidney Institute would not, under any circumstance, leave messages regarding sensitive medical information.

Acknowledging that it may be difficult for the physician/physician’s staff to personally communicate with the patients regarding laboratory/diagnostic test results, etc. it is the policy of Texas Kidney Institute to leave this information on patients’ telephone answering machine.

If the physician/physician’s staff cannot reach the patient at home or business telephone, it is the policy of Texas Kidney Institute that a message will be left with the person that answers the telephone to advise the patient to return the phone call.

It is the policy of Texas Kidney Institute not to release confidential medical information to patient’s family members. We cannot discuss your medical condition, or release diagnostic test results to any one without your consent.

It is the policy of Texas Kidney Institute to participate in clinical research designed to improve quality of patient care; this may necessitate the review of the patient’s medical records by the research staff.*

I agree
I disagree

I authorize Texas Kidney Institute to view my prescription history from external sources*

I agree
I disagree

I Have Read and have full understanding and agree to the terms of the Financial Policy and Agreement of Texas Kidney Institute (Straightline Medical Consultants)
I Acknowledge that I have read the below Notice of Privacy Practices with an effective date of March 15th 2012, and I understand that if I have any questions regarding this Notice, I may contact the Privacy Officer.
It is the policy of Texas Kidney Institute to participate in clinical research designed to improve quality of patient care; this may necessitate the review of the patient’s medical records by the research staff.
I authorize Texas Kidney Institute to view my prescription history from external sources

Signature

I have received or read a copy of this office’s Notice of Privacy Policy.

Patient Signature/Guarantor*

First Last

Date*

Electronic Signature Agreement

By selecting the "I Accept" button, you agree your electronic signature (hereafter referred to as "E-Signature") is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept", you consent to be legally bound by this Agreement's terms and conditions. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Texas Kidney Institute. You also represent that you are authorized to enter into this Agreement and that you will be bound by the terms of this Agreement.

I Accept

Name

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