Credit Form

* = Required

Maryland Endoscopy Patient Information

Name * Date * Account # * SSN # (optional) Date of Birth * Address * City * State * Zip Code * Marital Status * Sex * Race * Ethnicity * Preferred Language * Cell Phone * Landline Work Phone Email Address * Would you like to be registered with the patient portal? * Employed? * Employer Okay to leave message? Student? * Emergency Contact Name * Relationship * Emergency Contact Phone Number * Primary Care MD * Phone Number * Specialist MD * Phone Number * Specialist MD * Phone Number *

Pharmacies

Local Pharmacy Name * Phone Number * Local Pharmacy Name * Phone Number * Local Pharmacy Name * Phone Number * Primary Insurance Company * Policy Number * Group Number * Policy Holder Name * Policy Holder DOB * Policy Holder Relationship * Secondary Insurance Company Policy Number * Group Number * Policy Holder Name * Policy Holder DOB * Policy Holder Relationship * Tertiary Insurance Company Policy Number * Group Number * Policy Holder Name * Policy Holder DOB * Policy Holder Relationship *

INSURANCE AUTHORIZATION AND ASSIGNMENT

I understand that physician phone calls are telehealth visits and that online patient portal messages requiring physician input are billable services.

I authorize Maryland Endocrine, P.A. to apply for benefits on my behalf for covered services rendered.

I certify that the information I have reported with regard to my insurance coverage is correct. I further authorize the release of any necessary information, including medical information for this or any related claim to my insurance carrier. (Or in the case of Medical Part B benefits to Social Security Administration and Health Care Financing Administration).

I authorize payment of medical insurance benefits which are payable to me under the terms of my insurance to be paid directly to Maryland Endocrine, P.A. for services rendered. I further authorize the use of any information needed for processing my insurance claims. A copy of this authorization may be used in place of the original.

This authorization may be revoked either by me or my insurance carrier at any time in writing. I understand and agree that I am financially responsible for charges not paid by my insurance company.

I accept the terms of authorization *

I allow MARYLAND ENDOCRINE, P.A. to release any information relevant to my care to:

Provider Name: Relationship Provider Name: Relationship

Patient History

Age * Height *

Past Medical History

Please select all that you have or have had

Diabetes: *

What age were you when you were diagnosed with diabetes? Retinopathy laser needed? When was last eye exam? * Eye Doctor's Name *

Thyroid: *

Heart: *

If you aswered "Other" to the previous question, please write in your answer here. If you aswered "Other" to the previous question, please write in your answer here. If you aswered "Other" to the previous question, please write in your answer here. If you aswered "Other" to the previous question, please write in your answer here. If you aswered "Other" to the previous question, please write in your answer here. If you aswered "Other" to the previous question, please write in your answer here. Have you previously been diagnosed with COVID-19? * If you answered "Yes" to the previous question, please provide the date(s) of diagnosis (format: mm/yy) COVID Vaccination? *

Surgeries

Select all that apply

Surgeries *

Please provide details of "other" surgeries here. If applicable, please provide details of your transplant here. If you selected any surgeries, please provide the dates here. (Example: "Gallbladder: 01/04/2018")

Family History

(Parents, grandparents, siblings, children)

High blood pressure: Heart attack: Stroke: Diabetes (Adult onset/type 2): Diabetes (Juvenile onset/type 1): Thyroid (Hypothyroid/Underactive): Thyroid (Hyperthyroid/Overactive): Thyroid (Nodules): Thyroid (Goiter): Cancer / Type: Other diseases that run in your family:

Social History

Occupation Marital Status Total # of children # of sons # of daughters Smoking History: * If you selected "Former Smoker", please choose the approximate date that you quit. Alcohol History: * If you selected "Social Drinker", please recrod the amount that you typically drink. Exercise: * If you answered "Yes" to the previous question, please record the frequency and types of exercise. Special Diet: * If you answered "Yes," what are your dietary restrictions?

Review of Systems

select if you currently have problems with

General:

Weight Loss

Weight loss
Weight gain
Fatigue
Insomnia

Weight change details

HEME

Easy Bruising
Anemia

Gynecological

Irregular Periods
Heavy Periods
Infertility
Post-menopausal

Lungs

Wheezing
Cough
Shortness of Breath

Skin

Excessive acne
Excessive Hair Growth (women)
Excessive Hair Loss (men)
Vitiligo

If you selected "Numbness," please record the location of the numbness (hands, feet, jaw, etc.)

Musculoskeletal

Arthritis
Back Pain
Joint Swelling or Stiffness
Fractures

If you selected Fractures, please list what is fractured below.

Psychiatric

Depression
Anxiety

If you selected "Depression," please choose your treatment type. If you selected "Anxiety," please choose your treatment type.

Medications

Include your over-the-counter medications as well as any diabetes supplies. For insulin, include whether pen or vial and the concentration (U-100, U-200, U-300, U-500).

Medication *

Dose * Frequency *

Times taken *

Patient Acknowledgement form

MARYLAND ENDOCRINE, P.A. "Notice of Privacy Practices" provides information about how we may use and disclose protected health information about you. Please acknowledge receipt of this office's notice of Privay Practices by checking the box. * Our Notice of Privacy Practices states that we reserve the right to change the terms described. Should this hapen, this office will post changes in our waiting room area. You will receive a revised copy at your scheduled visit. * You have the right to request restrictions on how your protected health information may be used or disclosed for treatment, but if you do, we are bound by our agreement with you. *

Records Release

I, ______, BORN ______ HEREBY AUTHORIZE ______ TO RELEASE TO: Maryland Endocrine, Columbia M.D., 21044. F# 301-953-3543

Releasing party: * Doctor or Practice name: * Street * City * State * Zip * Phone * Fax *

Any information from the diagnosis and records of any treatment or examination rendered to me during the period from ______ to ______.

From: * To: *

I understand that this authorization shall be effective for a period of one year unless otherwise noted. I understand that I may cancel this requst with written notification but that it will not affect andy information released prior to notification of cancellation. I understand that the information used may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal regulations. I understand that the medical provider to whom this is authorized if furnished may not condition its treatment of me on whether or not I sign the authorization.

All requests for chart copies may be charged at the rates established acceptable by Maryland State law.

Please use your mouse, stylus, or finger to sign your name in this box.

By signing and submitting this form, I certify that the information provided through this form is accurate to the best of my knowledge.

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