New Patient Information

I am here for my first appointment with: *

Internal Medicine - Preeti Rana, M.D.
Nephrology and/or Hypertension, - Aysha Farooqi, M.D.
Nephrology and/or Hypertension, - Irmindra (Inder) Rana, M.D.
Nephrology and/or Hypertension, - Waqas Memon, M.D.
Nurse Practitioner - Lori Bagla NP
Nurse Practicioner - Yael E Daniel, NP

Date of Birth *

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Phone *

Home Phone

Work Phone

Email *

Email

Confirm Email

Would you like to list an emergency contact? *

Yes
No

Consent *

I DO consent to Text messaging/ email from Dr. Rana's office.
I DO NOT consent to Text messaging/ email from Dr. Rana's office.

Insurance *

I have current/active health insurance.
I am currently uninsured and would like to pay for my visits in full, at the time of service.

Advanced Directive: *

I DO NOT have an advanced directive and or I'd like to discuss/get information regarding
I have an advanced directive and or I have no interest in advanced directives

If at any time you change your mind, feel free to contact our office and/or make an appointment with the physician.

PATIENT'S MEDICATION FORM

Pharmacy Name *

Pharmacy Address

Address Line 1

City

State

Pharmacy Phone

Allergies *

I DO HAVE ALLERGIES
NO KNOWN ALLERGIES

Medication *

I do not currently take any prescription medication
I currently take over the counter medication
I currently take prescription medication
I currently take vitamins and/or herbal preparations

PATIENT'S MEDICAL AND SURGICAL HISTORY

Please Answer Yes or No to the Following Disorders and given explanation necessary.

High Blood Pressure *

Yes
No

Heart Attack / Angina *

Yes
No

Congestive Heart Failure *

Yes
No

Heart Murmur *

Yes
No

Mitral Valve Prolapse *

Yes
No

Cardiac Surgery *

Yes
No

Irregular Heartbeat *

Yes
No

Internal Defibrillator / Pacemaker *

Yes
No

Carotid Stents *

Yes
No

Asthma / Emphysema / COPD *

Yes
No

Lung Disease / Hepatitis / Tuberculosis *

Yes
No

Infectious Disease *

Yes
No

Kidney Disease *

Yes
No

Bladder Problems *

Yes
No

Ulcerative Colitis *

Yes
No

Hemorrhoids *

Yes
No

Autoimmune Disorder *

Yes
No

Family History Colon Cancer *

Yes
No

Back / Neck Problems *

Yes
No

Any Joint Replacement *

Yes
No

Arthritis *

Yes
No

Seizures *

Yes
No

Stroke *

Yes
No

Anxiety *

Yes
No

Thyroid Problems *

Yes
No

Breast Cancer *

Yes
No

Cancer *

Yes
No

Bleeding Disorder *

Yes
No

Sleep Apnea *

Yes
No

Reflux Esophagitis *

Yes
No

Urinary Disorder *

Yes
No

Polyps / Colon *

Yes
No

Depression *

Yes
No

Irritable Bowel Syndrome *

Yes
No

Reason for the Visit *

Any Past Major Surguries *

Please put N/A if there are none.

What is your sex? *

Male
Female

Allergies to contrast? *

IV
Dye
No

Allergies to Latex? *

Yes
No

Allergies to Shellfish? *

Yes
No

Allergies to tropical fruit such as banana? *

Yes
No

SOCIAL HISTORY QUESTIONNAIRE

Are you Retired?

Yes
No

Number of Children

Marital Status

Do you currently smoke? *

Yes
No

Did you smoke in the past? *

Yes
No

Alcohol Use *

Yes
No

Drug Use *

Yes
No

NOTICE OF PRIVACY PRACTICES ACKNOWLDEGEMENT

I understand and acknowledge that under the Health Insurance Portability and Accountability Act of 1996, hereafter known as "HIPAA", I have certain rights to privacy regarding my protected health information, I understand that this information can and will be used for the following:

Conduct, plan and direct treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly
Obtain payment from third party payers
Conduct normal healthcare operations such as quality assessments and physician's certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health care information. I understand KDPNVA, has the right to change its Notice of Privacy Practices at any time.

I also understand that I may request, in writing that you restrict how my protected / private health care information is used or disclosed to carry out treatment, payment or health care operations, it is also my understanding that you are not required to agree to my requested restrictions, however if you do agree or are obligated to abide by any such restrictions.

Patient Signature *

Clear Signature

In Addition to releasing my protected health information to health care providers for treatment and/or payment, you may also discuss and/or release my health care information records to?

Please include name and their relationship to you.

FINANCIAL & CANCELATION POLICY

Thank you choosing us for you healthcare needs. Our goal is to provide and maintain a good physician-client relationship . The following is our Financial Policy, which we ask you to review and sign prior to your first visit.
(PLEASE PLACE YOUR INITIAL IN THE BLANK SPACE INDICATED)

General Information *

Clear Signature

(Initial) Your co-payment, deductible, coinsurance, or payment in full is due at the time of service. We accept checks and cash at this time.

Regarding Insurance *

Clear Signature

(Initial) We participate in a wide variety of managed care plans. We are happy to bill your insurance carrier as a courtesy to you. We suggest that all patients review their health coverage with their carrier prior to receiving services or treatment. It is the responsibility of the patient to notify us of any changes in the insurance policy. Your insurance policy is a contract between you and your insurance company and our staff will not know the therms of your insurance policy. Please be aware that some, perhaps all, of the services provide may be non-covered services and not considered reasonable and necessary under the Medicare program and/or other medical insurances. The patient/financial guardian will be responsible for any remaining balances,. Additionally, it is your responsibility to obtain and track referrals for your visits.

Self-Pay Patients *

Clear Signature

(Initial) Patients without insurance are expected to pay at the time of service.

Worker's Compensation

Clear Signature

(Initial) we will bill your employer's worker's compensation insurance carrier and follow all other procedures as required by the states worker's compensation laws. As the patient, it is your responsibility to notify us prior to the with appropriate worker's compensation policy information.

Automobile and Other Liability Cases

Clear Signature

(Initial) Due to state laws surrounding auto insurance payments, as well as payments delays, we regret that we may not be able to bill third party administrators in liability cases. In addition, we cannot suspend our normal billing and collection process when services are rendered. Your health insurance carrier or the guarantor will be billed for services.

Returned Checks *

Clear Signature

(Initial) There will be a $30.00 returned check fee on all returned checks. In the event that a check is returned for insufficient funds, we reserve the right to call your bank for any future checks that are presented for payment on your account.

Missed Appointments *

Clear Signature

(Initial) Unless cancelled at least 24 hours in advance, your appointment could be considered a no-show. Our policy allows us to charge up to $50.00 for these types of missed appointments. Please help us serve you better by keeping your scheduled appointments.

Thank you understanding our Financial Policy. Pleases let us know if you have any questions or concerns. Please sign below to express your understanding and agreement to this financial policy.

Patient Name *

Date *

Patient/Responsible Party Members Signature *

Clear Signature

Responsible Party Member's Name (Print)