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PATIENT INFORMATION
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| #1 Insurance Company: |
INSURANCE COVERAGE
Primary Insurance Company
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Secondary Insurance Company (if applicable)
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MEDICAL INFORMATION
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| When did problem start?: |
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| Please describe in detail about present problem: |
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| Do the following apply?: |
Smoke Drink Other |
| Please list any allergies you have: |
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| Indicate if you have any of the following problems: |
Arthritis Asthma Blood Clots Cancer
Cardiac Bypass Circulation Problems Diabetes
Emphysema Heart Attack Heart Disease
Heartburn High Blood Pressure Kidney Disease
Kidney Stones Seizures Stroke
Thyroid Disease Varicose/Spider Veins Other |
| If other, please indicate: |
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| Please descirbe any major health concerns with family members: |
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| Have you ever had surgery?: |
Yes No |
| If so, give date, location, physician, and reason: |
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| Have you had any recent medical testing?: |
Yes No |
| If so, give date, location, physician, and procedure: |
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| Please describe any symptoms you are having: |
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I authorize Dr. Kamran Goudarzi, MD, its physicians and health care professionals, to disclose health information from my records to family, providers, potential providers, clinics, hospitals, surgical centers, insurance companies, and any other representative that is deemed necessary in providing healthcare and its related services. The facility, its employees, officers, and physicians are hereby released from any legal responsibility for disclosure of this information to the extent indicated and authorized herein. I understand that if I choose not to release consent to the parties named herein, I must complete a seperate form to indicate specific disclosure instrucitons. This form is available by the provider upon request.
Authorized Not Authorized |
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Dr. Kamran Goudarzi, MD is required to provide you with a Notice of our Privacy Practices, which states how we may use and/or disclose your health information. Please review this online and select the appropriate button below to indicate you have reviewed, received, and understand this policy.
Acknowledged Not Acknowledged |
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I authorize the release of any medical information necessary to process health insurance claims. I request payment of benefits be made directly to Kamran Goudarzi, MD. Any unexpected balance left after insurance payment has been received will be due in full within 30 days of notification from this office.
Authorized Not Authorized |
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I give my consent to Kamran Goudarzi, MD, its physicians and health care professionals, to provide treatment, examinations, and/or evaluations, etc. as deemed necessary.
Authorized Not Authorized |
| Electronic Signature: |
By indicating my full name and today's date below, I am electronically signing the information submitted above as being true and accurate to the best of my knowledge. I also understand and acknowledge that a paper version of these forms were made available to me for completion; however, I have chosen to submit them online. I understand that I may still be required to complete and/or sign a paper form for certain procedures and/or conditions.
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