Houston Bariatric Surgery Bariatric New Patient Information

Houston Bariatric Surgery: New Patient Forms 1

Houston Bariatric Surgery

Bariatric New Patient Information

Name: __________________________________________________ DOB: __________________

SSN:______-_____-__________ Marital Status: Married Single

Address: _____________________________________________________________________________

Mailing Address (if different): ____________________________________________________________

Street name City State Zip Code

Email Address:________________________________________________________________________

Phone: Home: _________________ Mobile: ___________________ Work: _______________________

May we leave confidential messages on these voice mails? Yes or No

Indicate if you would like mailed correspondence from our office sent in a sealed envelope marked

“confidential”? Yes or Not necessary

Please list family members or other persons with whom we may leave information about your

medical condition/diagnosis (including treatment/payment/health care options):

Employer: ____________________________________________________________________________

Employer’s Address: _______________________________ Phone: ______________________________

Emergency Contact Name: _______________________________Relationship: ___________________

Emergency Contact Phone: ______________________________________________________________

Referral Source: _____________________________________ Phone: ___________________________

Health Insurance Information:

Name of Insurance Company:_________________________________________________________

Policyholder: _____________________________ Policyholder’s DOB: ____________SSN:__________

ID Number: ______________________________ Group Number: _______________________________

Relationship: _________________________ Policyholder’s Phone #: ____________________________

Street name City State Zip Code

Houston Bariatric Surgery: New Patient Forms 2

Secondary Insurance:________________________________________________________________

Policyholder: _____________________________ Policyholder’s DOB: ____________ SSN: _________

Relationship: ________________ ID Number: _________________ Group Number: _____________

Insurance Authorization and Medical Release Form

I hereby authorize Jason M. Balette, MD, FACS, &/or Drew Howard, MD, FACS, to furnish or

obtain medical records concerning my illness and treatment to insurance carrier or medical

facilities. I hereby assign to the physician all payments for medical services rendered to my

dependents or myself. I understand that I am responsible for all charges regardless of insurance

coverage. Co-payment is to be paid at the time of office visit, as well as any payments towards

deductibles.

Signature : __________________________________________ Date: _____________________

Consent for Use of Email Address

• For appointment reminders.

• To inform you of benefits and services related to your health.

• Keep you updated on the approval process for Bariatric/General Surgery.

• Get your questions/concerns answered in a timely manner.

• Through the use of online surveys emailed to you by SGOTW physicians, its affiliated

entities and business associates, to allow you to communicate your opinion of our staff,

facilities and services received.

• As required by law and for certain law enforcement activities.

• As otherwise described in our Joint Notice of Privacy Practices.

Except as described above, we will not use or disclose your email address unless you authorize (permit) SGOTW

physicians in writing to disclose your email address. If you initially give permission, you may revoke that

permission, which will be effective only after the date of your written revocation. Declaration: I have read and

understand the about agreements and authorizations. The terms and consequences of this document have been

fully explained to me and I have signed it freely and without inducement other than the rendition of services. All of

my questions have been fully answered.

Signature: _________________________________________ Date: _____________________

Houston Bariatric Surgery: New Patient Forms 3

Patient Name: ________________________________________________________________

Occupation: __________________________________________________________________

Primary Care Physician: ____________________________ Address/Fax: _______________

Other Physician: ___________________________________ Address/Fax: _______________

Pharmacy: ________________________________________ Phone: _____________________

Medication List: (only list names, not dosages. Include vitamins & over the counter meds)

______________________________________________________________________________

Medical History: (currently being treated for, or history of. Please write N/A in “other")

Hypertension High Cholesterol Blood Clots

Anemia Sleep Apnea Lung Disease/Asthma

Diabetes Kidney/Bladder problems Stroke

Seizures Stomach Ulcers GERD

CHF/Heart Disease Alcoholism/Addiction Depression/Anxiety

Abuse Thyroid disorder PCOS

HIV/AIDS Liver problems/Hepatitis Tuberculosis

Chronic Pain Cancer Arthritis

Other: _______________________________________________________________________________

Allergies: _____________________________________________________________________

Surgical History (with dates):

Appendectomy: ______________________________ Gallbladder: ______________________________

Hernia Repair: _______________________________ Weight loss surgery: ________________________

Hysterectomy: _______________________________ Heart/Cardiac: _____________________________

Orthopedic: _________________________________ Other: ___________________________________

Houston Bariatric Surgery: New Patient Forms 4

Family History: please check conditions that apply

Blood Relatives

Obesity

Diabetes

Hypertension

Sleep

apnea

High

cholesterol

Hiatal

hernia

Mother

Grandmother

Grandfather

Father

Grandmother

Grandfather

Siblings

Children

Review of Systems (circle any symptoms you are currently experiencing)

Gastrointestinal: Nausea Vomiting Abdominal Pain Diarrhea Constipation Heartburn

Cardiovascular: Palpitations Chest Pain Rapid Heart Rate Edema

Respiratory: Shortness of Breath Cough Sleep Apnea/Snoring Wheezing Congestion

Musculoskeletal: Joint Pain/Swelling Decreased range of motion Exercise intolerance Muscle Pain

Neurological: Dizziness Memory loss Numbness/tingling Weakness Seizures Depression

Tobacco Use: Never Current Quit (year): _____________________________

Type used: Cigarettes Cigars Pipe Smokeless

Amount Used per day: ________________________ Number of Years: __________________________

Alcohol Use: Never Current Quit (year): ___________________________________

Type Used: Beer Wine Liquor Amount per week: ______________________________

Illegal Drugs: Never Current Quit (year): ___________________________________

Type Used: Cocaine IV drugs Pain Pills Other: __________ Amount/week: ____________

Houston Bariatric Surgery: New Patient Forms 5

Weight History:

Birth Weight: _____________________________ Start of High School: __________________________

High School Graduation: ____________________ Marriage: ___________________________________

Lowest weight in past 5 years: ________________ Highest weight in past 5 years: __________________

Exercise Habits:

Type of exercise: ________________________ Number of times/week & duration: _________________

Diet History:

(please list any diets or weight loss plans attempted in the past)

_____________________________________________________________________________________

Eating Habits:

(circle those that apply)

Snacking/Grazing 3 meals/day 2 meals/day Skip Breakfast Skip Lunch Skip Dinner

Average weight lost with each diet attempt: ________________________________________________

Most successful diet or weight loss plan: ___________________________________________________

Weight loss medications taken in past/currently: ____________________________________________

Other weight loss methods attempted: ____________________________________________________

Why do you want to lose weight? _________________________________________________________

_____________________________________________________________________________________

Are you or could you be pregnant? _____________________________________________________

Would you like your doctor to pray with you? ___________________________________________

How did you hear of us/who referred you? ______________________________________________

Houston Bariatric Surgery: New Patient Forms 6

Houston Bariatric Surgery

Written agreement to comply with therapy

I have reviewed all of the information, including reading the bariatric manual and viewing the bariatric

seminar, which has been provided to me by Dr. Jason Balette and/or Dr. Drew Howard. Information has

been provided regarding obesity, options for surgical weight loss including the vertical sleeve

gastrectomy, Roux-en-Y gastric bypass, and/or adjustable gastric banding. It is imperative that I follow

the strict post-operative dietary program with lifestyle modifications which include increased exercise. I

also understand that follow-up clinic visits are an important aspect of care to avoid potential

complications and for optimal weight loss. I have been given an opportunity to ask questions regarding

management of my obesity, alternative forms of treatment, risk of non-treatment, the procedures to be

used, and the risks involved. I believe that I have sufficient information concerning the procedures named

above. I agree to comply, to the best of my ability with all therapy and recommendations made by my

physician and healthcare providers, including: (please initial)

____ I will take a bariatric-specific multivitamin and calcium supplement for the rest of my life.

____ I will follow the guidelines of the pre- and post-operative diet.

____ I will exercise on a regular basis after surgery.

____ I will not get pregnant for at least 2 years after my surgery.

____ I will quit smoking 2 months before surgery and remain smoke-free for the rest of my life.

____ I will follow up in clinic after surgery at 2 weeks, 3 months, 6 months, 12 months, & annually.

_______________________________ ________________________

Signature of patient Date

_______________________________ ________________________

Signature of provider Date

Houston Bariatric Surgery: New Patient Forms 7

Jason Balette, M.D., F.A.C.S.,

Drew D. Howard, M.D., F.A.C.S.

Thank you for choosing us as your health care provider. We are committed to your treatment being successful.

Please understand that payment of your bill is considered a part of your treatment. The following is a statement of

our Financial Policy that we require you read and sign prior to any treatment.

All patients must complete our Information and Insurance form before seeing the doctor.

• FULL PAYMENT IS DUE AT TIME OF SERVICE

• WE ACCEPT Cash, Checks, Visa, or MasterCard

Regarding Insurance

We may accept assignment of insurance benefits. The balance is your responsibility whether your insurance

company pays or not. We cannot bill your insurance company unless you give us your insurance information. You r

insurance policy is a contract between you and your insurance company. We are not a party to that contract.

If your insurance company has not paid your account in full within 45 days, the balance will automatically be

transferred to you as the guarantor. Please be aware that some, and perhaps all, of the services provided may be

non-covered services and not be considered reasonable and necessary under the Medicare Program and/or other

medical insurance, see attached ABN. Regarding Insurance Plans where we are a participating provider, all co-pays

and deductibles are due prior to treatment. In the event that your insurance coverage changes to a plan where we are

not participating providers, refer to above paragraph.

Disclosure of Ownership:

Houston Bariatric Surgery is a physician owned facility and your physician may have a financial interest in a surgery

center, laboratory or other entity where you may be scheduled for treatment. You have the right to choose where

you receive medical and surgical services including an entity in which your physician may have a financial

relationship.

Usual and Customary Rates

Our practice is committed to providing the best treatment for our patients and we charge what is usual and

customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary

determination of usual and customary rates.

Adult Patients

Adult patients are responsible for full payment at time of service.

Minor Patients

The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment.

Surgery

Deductible, co-insurance and co-payments are due prior to surgery date, unless other arrangements have been made.

SIGNATURE __________________________________________ Date ____________

Houston Bariatric Surgery

Houston Bariatric Surgery: New Patient Forms 8

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT

Name: __________________________________________D.O.B.____________________________

SECTION B: TO THE PATIENT--PLEASE READ THE FOLLOWING STATEMENTS

CAREFULLY.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected

health information to carry out treatment, payment, and health care operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign

this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses

and disclosures we may make of your health information, and of other important matters about your health information. A

copy of our Notice is available upon request. It is also posted in our office.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our

privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may

apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions, at any time by

contacting:

The Surgical Group of the Woodlands

9200 Pinecroft Suite 250

The Woodlands, TX 77380

Ph. (281)419-8400

Fax (281)292-1972

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation

submitted to the address above. Please understand that revocation of this Consent will not affect any action we took in

reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating

you if you revoke this Consent.

SIGNATURE

I have had full opportunity to read and consider the content of this Consent form and your Notice of

Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of

my protected health information to carry out treatment, payment activities and health care operations.

Signature: _______________________________________________Date______________________

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative's Name:______________________________________________________

Relationship to patient: ______________________________________________________________

Houston Bariatric Surgery

Houston Bariatric Surgery: New Patient Forms 9

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

IT CAREFULLY.

1. OUR PLEDGE REGARDING MEDICAL INFORMATION

At The Surgical Group of the Woodlands we are committed to treating and using protected health information about you

responsibly. We understand that your medical information is personal and we are committed to protecting it. We create a record of

the care and services you receive at our organization. We need this record to provide you with quality care and to comply with

certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also

describe your rights and certain duties we have regarding the use and disclosure of medical information.

2. OUR LEGAL DUTY

Law Requires Us to:

1. Keep your medical information private.

2. Give you this notice describing our legal duties, privacy practices, and your rights regarding medical information.

3. Follow the terms of the current notice.

We Have the Right to:

1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.

2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep,

including

information previously created or received before the changes.

Notice of Change to Privacy Practices:

1. Before we make an important change in our privacy practices, we will change this notice and make the new notice

available upon request.

3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION

The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be

listed.

However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or

disclose your

medical information for any purpose not listed below, without your specific written authorization.

FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may

disclose medical information about you to doctors, nurses, technicians, medical students, or other people taking care of you. We

may also share medical information about you to your other health care providers to assist them in treating you.

FOR PAYMENT: We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-

party payer. The information on or accompanying the bill may include your medical information.

FOR HEALTH CARE OPERATIONS: We may use and disclose your medical information for our health care operations. This

might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and

getting the accreditation, certificates, licenses and credentials we need to serve you.

ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment,

payment, and health care operations, we may use and disclose medical information for the following purposes.

Facility Directory: Unless you notify us that you object, the following medical information about you will be placed in our

facility directories: you name; your location in our facility; your condition described in general terms; your religious affiliation, if

any. We may disclose this information to members of the clergy or, except for your religious affiliation, to others who contact us

and ask for information about you by name.

Notification: We may use and disclose medical information to notify or help notify; a family member, your personal

representative or another person responsible for your care. We will share information about your location , general condition, or

death. If you are present, will get your permission if possible before we share, or give you the opportunity to refuse permission.

In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is

directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to

Houston Bariatric Surgery: New Patient Forms 10

make decision in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information

for you.

Disaster Relief: We may share medical information with a public or private organization or person who can legally assist in

disaster relief efforts.

Research in Limited Circumstances: We may use medical information for research purposes in limited circumstances where the

research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the

privacy of medical information.

Funeral Director, Coroner, and Medical Examiner: To help them carry out their duties, we may share the medical information

of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.

Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military

personnel and veterans, for nation’s security and intelligence activities, for correctional institutions and other law enforcement

custodial situations, and for government programs providing public benefits.

Court Orders and Judicial and Administrative Proceedings: We may disclose medical information in response to a court or

administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited

circumstances, such as a court order,warrant, or grand jury subpoena, we may share your medical information with law

enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a

suspect, fugitive, material witness, crime victim or missing person.

Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities

charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your

medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse

events associated with product defector problems, to enable product recalls, repairs or replacements, to track products, or to

conduct activities required by the Food and Drug

Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to

communicable disease or otherwise be at risk of contracting or spreading a disease or condition.

Victims of Abuse, Neglect, or Domestic Violence: We may use and disclose medical information to appropriate authorities if we

reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.

We may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or safety

of others. We may share

medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime

or has escaped from legal custody.

Workers Compensation: We may disclose health information when authorized or necessary to comply with laws relating to

workers compensation or other similar programs.

Health Oversight Activities: We may disclose medical information to an agency providing health oversight for oversight

activities authorized by law, including audits, civil, administrative, or criminal investigation or proceedings, inspections, license

or disciplinary actions or other similar programs.

Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These

circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain

subpoenas or court orders, reporting limited information concerning identification and location at the request of a law

enforcement official, reports regarding suspects of crimes at the request of a law enforcement official, reporting death, crimes on

our premises and crimes in emergencies.

Appointment Reminders: We may use and disclose medical information for purposes of sending you appointment postcards or

otherwise reminding you of your appointments.

Alternative and Additional Medical Services: We may use and disclose medical information to furnish you with information

about health related benefits and services that may be of interest to you, and to describe or recommend treatment alternatives