Document Sample
					Glenn Anderson, MD                                     BURKE FAMILY PRACTICE P.C.                          Andrea Bonanno, FNP-BC
Amy Nobu, MD                                            9409-B Old Burke Lake Rd.                          Margaret Zimmerman, FNP-BC
Ken Moles, MD                                                 Burke, VA 22015                              Mariam Usman, FNP-BC
Janet Dougherty, MD
                                                     (703) 978-4200 Fax (703) 503-8263
We routinely put all family members on the same account number. If you are an adult, do you want to be put
on your OWN, separate account?      YES      NO     If yes, all correspondence/bills will go to you directly.

PATIENT INFORMATION ▼                                                                    Today’s Date

Full Name/Suffix                                                                         Date of Birth                        Male      Female

Social Security Number                                                                   PHONE NUMBERS ▼
Street Address/P.O.Box                                                                   Home #

City/State/Zip                                                                           Work #

Marital Status        Single   Married   Widowed     Domestic Partner                    Cell #


Patient Employer Name/Address/City/St/Zip or Student or None

INSURANCE POLICY HOLDER INFORMATION ▼                                                    Is the patient the policyholder?     Yes        No

Name of Insurance                                                                        Patient Relation to Policy Holder

Policy Holder Name                                                                       Policy Holder Phone #

Policy Holder Date of Birth                                                              Policy Holder Work #/Cell #

Policy Holder Address/City/St/Zip

Policy Holder Employer Name/Address/City/St/Zip

Have you provided the most Current Insurance Card to the Doctor’s Office? If NOT, fill in questions below. Claims cannot be filed properly
without the following information. If information is not complete or rejects, patient will be responsible for the claim.
Insurance Identification Number INCLUDING ALPHABETIC PREFIX (required)                      Group/Plan Number

Claims address                                                                           Copayment for Office Visit

MOTHER NAME/LEGAL GUARDIAN                                              FATHER NAME/LEGAL GUARDIAN

Mother Address                                                          Father Address

Mother City/St/Zip                                                      Father City/St/Zip

Mother Home #                                                           Father Home #

Mother Work #                                                           Father Work #

Mother Cell #                                                           Father Cell #

Mother Date of Birth                                                    Father Date of Birth

Minors must be accompanied by a parent or legal guardian unless written authorization from said parent/guardian is presented at visit.

Nearest Relative not living with you/EMERGENCY CONTACT NAME                                              Their Phone #

Other family members who’ve been seen at Burke Family Practice?

How did you hear about Burke Family Practice?            WEBSITE     Phone Book          Specialist Referral    Family      Friend   Insurance
Please Circle one
Glenn Anderson, MD                               BURKE FAMILY PRACTICE P.C.                      Andrea Bonanno, FNP-BC
Amy Nobu, MD                                       9409-B Old Burke Lake Rd.                     Margaret Zimmerman, FNP-BC
Ken Moles, MD                                           Burke, VA 22015                          Mariam Usman, FNP-BC
Janet Dougherty, MD
                                              (703) 978-4200 Fax (703) 503-8263

                                     HIPAA PRIVACY NOTICE TO PATIENTS
HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was signed into law on August 21, 1996,
Public Law 104-191. This law impacts all areas of the health care industry and was designed to provide insurance portability; to
improve the efficiency of health care by standardizing the exchange of administrative and financial data, and to protect the
privacy, confidentiality and security of health care information.
In order to comply with this legislation Burke Family Practice P.C. is required to provide this notice which describes how
medical information about you may be used and disclosed and how you can get access to this information. Please review it
The law does NOT require that we obtain authorization for use or disclosure of your medical information when we are directly
involved in your care, and when the use or disclosure is for purposes of providing treatment, obtaining payment, or
operations of the practice.
Examples of uses and disclosures for providing treatment:
If a provider at the practice refers you for a cardiac stress test and needs to call the cardiologist for results, the clinician may give
your name and the reason for ordering the test to the cardiologist’s office.
A provider or a member of our staff may call you or leave a message for you at the phone numbers you have provided, in order
to confirm an appointment, inform you about test results or advise you of treatment suggestions.
Please let us know if you wish to have kept in confidence the fact that you have an appointment; otherwise in the course of
telephone conversations to your home or family, such information may inadvertently be disclosed.
Examples of uses and disclosures to obtain payment:
The practice’s billing office may submit a claim form, containing your name, address, social security number, diagnosis and the
procedures performed in our office to your insurance company.
Examples of uses and disclosures to carry out operations of the practice:
The providers may audit your chart in order to track and improve our performance in assuring that screening tests and
immunizations are done on time.
We may leave messages at the telephone numbers you provide, asking you to return our call. Please let us know if you do
NOT want us to leave voice messages at any of the numbers you have provided.
The practice may use or disclose protected health information about you for other purposes, without your consent, if we are
required by law to disclose to governmental authorities. Such uses or disclosures may include:
Suspected abuse or child abuse
Documented communicable diseases
The practice will make other uses and disclosures of your protected health information only with your written authorization.
You have the right to revoke such authorization.
You have rights regarding your protected health information. You may:
Request restrictions on certain uses and disclosures of protected health information; we will make every effort to comply with a
requested restriction, but are not required to do so.
Request that you receive confidential communication of protected health information. You are responsible for letting us know if
this is your desire, and we will make all reasonable efforts to see that your protected health information, for purposes other than
treatment, payment or operations, are communicated only to you. At times this may require confirmation of your identity and/or
a written signed release form.
Request a copy of your own protected health information (a copying fee will apply and a signed release form willl be requested).
Request that your information be amended. Your request should be in writing and will be made a part of your medical record.
Request an accounting of disclosures of protected health information made by the practice in the past six years.
Request a paper copy of this notice.
The practice is required to act on your request within 60 days.
The practice is required by law to maintain the privacy of protected health information and to provide individuals with notice of
its’ legal duties and privacy practices with respect to protected health information.
The practice is required to abide by the terms of this notice and to provide individuals with revisions to the notice.
You may complain to the practice, or the Secretary of Health and Human Services, if you believe that your privacy rights have
been violated. File a complaint with the practice by writing to the Privacy Officer, Burke Family Practice, 9409-B Old Burke Lake
Road, Burke, VA, 22015. No one will attempt to retaliate against you for filing a complaint.

Effective Date: April 14, 2003
I have reviewed this notice and believe I understand my right to privacy.

__________________________________________________                     _________________________________________________
Patient’s Name                                                          Responsible Party (if patient is under age 18)

Signature                                                                Date                                                03/10
Glenn Anderson, MD                                  BURKE FAMILY PRACTICE P.C.                 Andrea Bonanno, FNP-BC
Amy Nobu, MD                                          9409-B Old Burke Lake Rd.                Margaret Zimmerman, FNP-BC
Ken Moles, MD                                              Burke, VA 22015                     Mariam Usman, FNP-BC
Janet Dougherty, MD                              (703) 978-4200 Fax (703) 503-8263

                                                   FINANCIAL POLICY
                This is an agreement between Burke Family Practice, P.C., and the responsible party named on this form.
Monthly statement: If you have a balance on your account of $5 or more, we will send you a monthly statement showing
charges to the account; the finance charge, if any; payments or credits applied; and the date the balance is due. If your
balance is $3.50-$4.99 and over 30 days old, the software billing program will generate a statement with a finance charge.
Please call office if your bill generated a finance charge on a bill of $3.50-$4.99.
Payments: Unless other arrangements are approved by us in writing, the balance on your statement is due by the 12th of
the month and is past due if not paid by the next billing cycle. If your account becomes past due, we will take all
necessary steps to collect this debt. If we have to refer your account to a collection agency or lawyer you agree to pay all
the collection/lawyer/court fees that are incurred. If you are referred to a collection agency, you and others on your
account will be dismissed from the practice.
Required payments: Any co-pays required by your insurance company must be paid at the time of service. Failure to pay
this required fee will result in an additional $20 service charge.
Payment options if you have no insurance:
1. You may choose to pay by cash, check, or credit card on the day that treatment is rendered.
2. On bills with extensive procedures you may choose to pay 50% on the date of service and the balance in three weeks.
3. Under special circumstances a payment plan can be arranged at the time of service.
Payment options if you have insurance:
1. If we are contracted providers with your insurance carrier, you will pay the co-pay at the time of service and be
responsible for any designated deductible or allowable charges.
2. If we are not contracted or participating providers with your insurance carrier, you will pay 100% of the charges at the
time of service. We can file your claims and you will be reimbursed directly by your insurance carrier.
3. We are Medicare participating providers. Patients pay nothing at the time of service but are responsible for the annual
deductible and 20% of the remaining Medicare allowable charges. Medicare Advantage programs usually require a co-
pay at the time of service.
4. We are Tricare authorized nonparticipating providers. By law our charges are 15% above those of participating providers.
You pay 100% at the time of service and are reimbursed directly by Tricare.
Insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most
cases. We can bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance
company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any
portion of the charges not covered by insurance. If your insurance company requires a referral and/or preauthorization,
you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower or no
payment from the insurance company.
Divorce: In the case of divorce or separation, it is the individual authorizing the treatment of dependent minors who is
ultimately responsible for the bill.
Finance charge: A finance charge will be imposed on each item of your account that has not been paid within one billing
cycle from the time the item was turned over to the patient's responsibility. The finance charge will be computed at a rate
of 1.5% per month/18%APR or $1.50 whichever is greater. The finance charge on your account is computed by applying
the periodic rate of 1.5% to the overdue balance of your account. The overdue balance on your account is calculated by
taking the balance owed as of the last billing cycle, and then subtracting any payments or credits applied to the account
during that time.
Returned checks: There is a fee, currently $25, for any check returned by the bank.
Missed appointments: These will be subject to a $50 fee. Abuse of this policy may result in dismissal from the practice.
Fee for completion of forms, reports and letters: A fee may be charged for the completion of forms or the writing of letters.
This fee is not reimbursed by health insurance carriers. The Provider will determine the fee based on the complexity of the
form and the time required in its’ preparation.
Transfer of Medical Records: A medical records copying fee will be assessed for all requests. You authorize us to include all
relevant information. A signed Records Release Form is required.
Workers compensation: We require written approval/authorization by your employer and/or workers compensation carrier
prior to your initial visit. If your claim is denied, you will be responsible for payment in full.
Auto accidents: Appointments for auto accidents are submitted through your health insurance at the time of service.
Should your health insurance deny the claim, you will be responsible for the charges. These charges then will need to be
filed by you or the responsible party to the auto insurance carrier.
Effective date: Once signed, you agree to all the terms and conditions contained herein and the agreement will be in full
force and effect.
___________________________________________________________              ________________________________________________________
Patient’s Name                                                              Responsible Party (if patient is under age 18)

Signature                                                         Date                                      03/10
Glenn Anderson, MD                                    BURKE FAMILY PRACTICE P.C.                       Andrea Bonanno, FNP-BC
Amy Nobu, MD                                            9409-B Old Burke Lake Rd.                      Margaret Zimmerman, FNP-BC
Ken Moles, MD                                               Burke, VA 22015                            Mariam Usman, FNP-BC
Janet Dougherty, MD
                                                (703) 978-4200         Fax (703) 503-8263

                                         BURKE FAMIILY PRACTICE ADULT PATIENT HISTORY
Last Name _________________________________First Name_________________________Middle Init_____________
Date of Birth________________________Home Phone_______________________Cell Phone____________________
Address (C/S/Z)_______________________________________________________________________________________
Country where born____________________________If born outside USA, years in USA_________________________
Years living in Northern Virginia__________________

                                                                    Current Medications Taken (including Herbal/homeopathic/over the counter products)
Active Medical Conditions (eg Hypertension, Diabetes)
                                                                           Medication:                  Dosage:                Reason for Taking:

      Medication Allergies or Adverse Reactions:
Medication:                 Reaction:

                             Hospitalizations                                                             Surgeries
Reason                                  Year                                Procedure                           Year

                                                           Other specialists that you see?

Problems with Anesthesia? Yes_________ No___________
Bleeding Tendencies? Yes__________No_______________
                                                                                                                                    Page one (03/10)
NAME_______________________________________________________________________________DATE OF BIRTH_______________________________
Smoking History? Never smoked_________ Quit smoking in__________ Currently Smoke___________ Pack/day_______How long__________
Other Tobacco Products? Never__________ Prior Use?____________ Currently Use?____________(chewing tobacco,snuff,pipe,cigar)
Alcohol Use? None__________ Less than 2 drinks/day__________ More than 2 drinks/day__________
Risk factors for Hepatitis/HIV/STD? Yes____________ No_______________ (This may include multiple blood transfusions, Occupational or sexual exposure,
or IV drug use.)
Do you use seatbelts? Always______________Sometimes________________Never________________
Family History Unknown or Adopted?
             CONDITION                          RELATION                             CONDITION                              RELATIONS

EPILEPSY OR SEIZURE DISORDER                                           KIDNEY DISEASE

DIABETES                                                               LIVER DISEASE

HEART DISEASE                                                          TUBERCULOSIS

STROKE                                                                 DIGESTIVE DISEASE

HIGH BLOOD PRESSURE                                                    LUNG DISEASE

BREAST CANCER                                                          OSTEOPOROSIS

COLON CANCER                                                           THYROID DISEASE

PROSTATE CANCER                                                        BLEEDING DISORDER

OTHER CANCER                                                           OTHER NEUROLOGIC DISEASE

                          WOMEN ONLY:                                                                     Exercise Habits

Approximate age of onset of menstruation:                                             How would you describe your exercise habits? Circle one

Last Menstrual Period?                                                    A.Couch potato (little or no exercise)
                                                                          B. Nothing formal, but I’m active on my feet much of the day
Have you reached Menopause? Yes________No________                         C. I try to do aerobic exercise 20-30 minutes a day, three days a week
                                                                          D. I actually do aerobic exercise 20-30 minutes a day, three days a
Number of Pregnancies____________
Number of Deliveries__________                                            E. I combine regular aerobic activity, 3-5 times a week, with strength or
                                                                          resistance work
Number of Miscarriages________ or Terminations_________
                                                                          F. I exercise vigorously 3-5 times a week, either playing sports or in a
                                                                          regular program of balanced fitness and strength training
               Health Maintenance (Provider Use Only)                     G. Elite Athlete

                                                                                             Family Status [(L) Living or (D) Deceased)]
 Pap Smear
                                                                               Member               L/D How?            Member             L/D How?
 Prostate Cancer screen                                                    Mother                                   Father
 Fecal Occult Blood (Stool) screen                                         Sibling                                  Sibling
 Cholesterol screen                                                        Sibling                                  Sibling

 Tetanus                                                                   Grandmother                              Grandfather

 Flu Vaccine                                                               Grandmother                              Grandfather

 Pneumonia Vaccine
                                                                                                                                        page two (03/10)

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