AMAZING MED CLINIC (AMC)

1125 CYPRESS STATION DR. BLDG. H SUITE 1 & 2, HOUSTON, TEXAS 77090
25311 INTERSTATE 45 NORTH, THE WOODLANDS, TEXAS 77380
(281) 866-7701 PHONE (281) 866-7705 FAX

PATIENT INFORMATION FORM

PATIENT’S PERSONAL HISTORY

PATIENT’S REVIEW OF SYSTEMS
Medication Dosage Frequency
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REVIEW OF SYSTEMS
Please answer yes or no below all symptoms




Authorization for Release of Medical Records To:
Authorization Form for Release of Protected Health Information






Acknowledgement of Review of Notice of Privacy Practices

I have reviewed this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed.
I understand that I am entitled to receive a copy of this document.



Authorization for Release of Medical Records from another Facility to AMC

I hereby authorize the release of information contained in my medical records to:


Annie Varughese, M.D, F.A.C.C




(281) 866-7701 PHONE (281) 866-7705 FAX (Woodlands)




All Medical Records

Cardiac Testing

EKG

Recent Labs

Recent Progress Notes



MEDICARE AND COMMERCIAL INSURANCE SIGNATURE ON FILE

I hereby request that payment of authorized Commercial Insurance and/or Medicare benefits be made on my behalf to AMAZING MED CLINIC (AMC). Dr. Annie T. Varughese for any services furnished me by the company listed. I authorize any holder of Medical Information about me to release to Medicare and/or Commercial Insurance and its agents any information needed to determine these benefits or the benefits payable to related services.


I understand my signature below requests that payment be made and authorized release of medical information necessary to pay the claim. If “other health insurance” is indicated in Block 9 of the HCFA1500 form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the provider or supplier agrees to accept the charge determined of the Medicare Carrier as full charge, and the patient is responsible for only the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination of the Commercial Insurance and/or Medicare Carrier.

Do you frequently have or have you been told that you have any of the following:




               




         










       
Neurocognitive Symptoms:Cognitive Test




Neurological and Musculoskeletal Symptoms: Electromyography/Nerve Conduction Velocity Test EMG/NCV




Do you experience ANY of the following (please circle those that apply):

           





Vestibular/Balance Symptoms: Videonystagmography Test VNG





Sleep Disturbance Symptoms Sleep Study *NO Medicare/BCBS/Humana Insurances accepted







*This History Update, which is included in your medical record, lists symptoms and other factors that contribute to your physician’s decision making in the recommendation of one or more diagnostic studies. Upon review and approval by your physician an outside diagnostic firm partnered with your physician will contact you to schedule your test(s).

Answer the following questions to find out if you are at risk for Obstructive Sleep Apnea.

Have you been told that you snore?
Are you often tired during the day?
Do you know if you stop breathing or has anyone witnessed you stop breathing while you are asleep?
Do you have high blood pressure or on medication to control high blood pressure?


If you answered YES to two or more questions on the STOP portion you are at risk for Obstructive Sleep Apnea. It is recommended that you contact your primary care provider to discuss a possible sleep disorder.



To find out if you are a moderate to severe risk of Obstructive Sleep Apnea, complete the final four questions.



Is your body mass index greater than 28?
Are you 50 years old or older?
Are you a male with a neck circumference greater than 17 inches, or a female with a neck circumference greater than 16 inches?
Are you a male?

The more questions you answer YES to on the BANG portion, the greater your risk of having moderate to severe Obstructive Sleep Apnea.

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