Dr. CanslerLas Vegas Medical Center

3835 S. Jones Blvd. Ste. l02BTel: 702-932-3176 Fax: 702-9St-9370

PATIENT INFORMATION

Home PhoneMobile #

Name Sex M F'(Last Name) (First Name) (M. t . )

AddressApt# City

Soc. Sec. #

State Zip Code

MaritalStatusBirth Date

Flrrrployer

Whom may we thank for referring you? _--

In case of emergency call (person not living with you)

Pcrson responsible for Account

Phone

PRIMARY INSURANCE

(Last Name) (First Name)

Birth date Soc. Sec #

Insured's Employer

Policy #

SECONDARY INSURANCE

Is patient covered by additional insurance? Yes No

Work Phone

RefDR. Phone

( M . t )

lnsurance Nane_

I{elation to Patient

Insurance Co. Phone # crp. #

lnsuranoe Co. Name_

Polisv # Grp #

Insurance Phone #

Insured's Name

lnsured's Birth date

Insured's LD. #

Relation to Patient

JInsured's Emaloyer

ASSIGI{MENT AND RELEASE \

I, the undersigned certify that I (or my dependant) have insurance coverage and assign directly to Dr. K4hlee.n Canstg{ ailinsutance benefits, ifany, otherwise payable to me for services rendered. I understand that I am responsibie for all chargeswllethcr or not paid by insurance and also responsible for paying any co-payment and deductibles that nry insurance does norcover" I here by authorize the doctor to release any information necessary to secure ihe payment ofbenefits. I authorize the uscof tiris signature on all insurance submissions.

Responsible Parfy Signature Relationship Date

L.,.;l;.,.- :'i;)i,:

It

i:+:

.__ lntgrnal Medicine

l'JameAddressl)hone (horne) (work)

lrrl'luenza: Pneumovax:i l cpB : HepA:I 'c ta tus: Rec Drugs:d"lu rrent Meds

SS#

History & Physicni

DateOccupation

Date of birth Age

Familv HistorvFatber Molher Father's Mother's

prents parenls Srbling Chridrerr

Heart Disease U

ltigh Blood Pressure fl

Strcrke

Cancer

Glaucoma

Diabetes

Epilepsy/ Conwlsions fl

Bleeding Disorder

Kidney Disease

'l hyroid Disease

Mental lllness

Osteoporosis

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f r &f f st t n

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Reason

Wgssepgdy Pregnant Yes trY

No tN Planning pregnancy Yes tr Noh,tEt)l( jAt.

f ,T I i i pr i rcnsit tl Dizziness/ Fainrine[ . [ i l ; . ,p*r l ipi t l*nria *__{.} I lcirrt l\,lrrrnru r

tl Heart Palpitationsilshortness of breath

lS Ar'rh,vt irnria tt orthopnea

ll Ulcer __ _ _H Anxierr,,8I cr niro.aei

---ili l,'otiru.

tt Mcnstrual oysrr*ritir-_-- tlln.,ri,,,, '.r.*

f l i irc'r ]rairr, \nginaI$ivr tlt ( liirtllrriii,rn

f,ll lcldaclresHl orh"r

EE Anemia tl z\sthmirttartnriris_____-__ --t*0sre,rp,ri,ii;s

-

Itcopo f,$ ['neunroniuItAtteigies / Hay f-everStStroke / 1'lAs

H ( ong,:slivr: hcart Discase83 Congostive I'lctrl Fpilurc'[l Scarlet F'ever {

f;l Eenereal Diseasc S[ Ci,"lutt[ Diabetes f,tlindoclinc l)iscrisr:

tt Rheumatic fevert| Other

B fpiiepsl_ -_- tl t-iver disease __ .tt other ttother

}{AI}I1'Sffi linroirc Pi.icks l)aily

llow L,ong'/lrrrerested in stopping? __

Sf Exercise routine:

St Coffee: Cuns dailvOlher {rafl'eine

fiAlcohol:

EDier

Tlpe

Sal intake

Fat intake

1992

f8 Sleep Diflicrrlty lalling aslrr:yr(iontin uitv disturbanccsSnoring

liarly rronting a*'akt-ning

I)ay-tinre ciroivsiness__,., -0ther

Amourt

tl*pafitis C Risk Factor: ltr Blood transfusion pnor ro fil IV clrug use ( l+ times) $l Ciirrtart rvilh i;tix;tlr bcri!ir iliri;i

Las Vegas Medical CenterPrivacy Notice

. This notice describes how medical information about you may be used and disclosed and how;; *" get accessto fhis information. Please review it carefully.

'l'his Privacy Notice is being provided to as a requirement of a federal law, the Health Insurance portability and. Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose your prot€cted heatthinftrrmation to carry out treatment, payment or health care operation anb for other purpose thai are permitted orrequircd bv law. lt also describes your right to access and conirol your protected health information in some cases.

Your o'protected health information' means any written and oral health information about youo includingr'lentographic data that can be used to identify you. This is health information that is created orreceivecl by fourhealth carc provider, and that relates to your past, present or future physical or mental heatth or conrlition.

A "Privacy Notice" is available upon request for your review: just ask the front office staff.

Plense sign where indicated below acknowledging you have been advised of the..Privacy Noticeoo and availabilityof your opportunity to review.

Patient Date

J

Las Vegas Medical CenterDISCLOSURE AUTHORIZATION FOR INTORMATION REQUEST

Pursuant to the l{ealth lnsurance portability and Accountabiliry Act (HIPAA), Iirerby'authoriz,e the following providers: _

Iu clisclose tle rottowingprotectea-he"tth irfo*"tiir" t" L"s v-grs nt"dtcal center.

Medical history, including specific progress notes regarding any problems thatwould impact my consult, office visit, surgery or procedure's progress or outcome.A list of allergiesResult ofrelevant diagnostic or laboratory test.Other

'l'i{is pfoi€cted health information is being used fbr primary care treatment provided by this Las Vegas Medical Center'l his authorization shall bt: in force and effective until

I understand that as set tbrth in l-as Vegas Medical Center Notice, I have the right to revoke this authorization, in writing,at any tirnc by sending written notification to:

L,as Veg,as Medical Centerllt i5 S. Jones Ste. | 028l .as Vegas, NV 89103A{tn: Privacy'Officer

I understand thal a revocation is not effective to the extent that Las Vegas Medical Center has relied on the use ol-d i sc losure tr{' the protected health information.

I trnderstand that information used or disclosed pursuant to this authorization may be re-disclosure by the recipient and mayno longer be protected by federal or state law.

I understand that Las Vegas Medical Center will not condition my treahnent on whether I provicle authorization for therequested use or disclosure.

I understand that I have the right to:

Inspect or copy rny protected health information (at a scheduled time) to be used or disclosed as permittecl un<Jer tbderallaiv ( or slate law [o extent the state law provides greater access rights).

refuse to sign this authorization. J

Signature of Patient or Representative Date

LAS VEGAS MEDICAL CENTf,RFINANCIAL STATEMENT

ALL CO.PAYS, DEDUCTIBLE OR CO.INSURANCE IS DUE AT THE TIME OF SERVICE. NOEXCEPTIONS LINLESS PRIOR ARRANGE MENTS FI,AVE BEEN MADE.

PAI"IENTS ARE RESPONSIBLE FOR PROVIDING LAS VEGAS MEDICAL CENTER WI TI IT]OIIREC.| INSURANCE INFORMATION. LAS VEGAs MEDICAL CENTER wILi.BIi,L YoUIJ\SIJRANCE AS A COT]RTESY AND IF PAYMENTS IS NOT MADE BY YOUR INSURANCE

WIl]tIN 90 DAYS OF YOUR DATE OF SERVICE YOU WILL BE BILLED AND HELSRESPONSIBLE FOR PAYMENTS IN FULL.

L]NDERSTAND THAT IF YOUR ACCOLINT IS REFERRED TO ATHIRD PARTY FORL]OLI.HCTION YOU WILL BE RESPONSIBLE FOR ANY AND ALI, COSTS RELATED TO 'IFIE

COi,LECTION AGENCY, INCLUDING BUT NOT LIMITED TO, COLLECTION AGENCYPTJRCT{NTAGE FEES, INTEREST, COURT COSTS AND REASONABLE ATTORNEY I.'EES.

AI-I, RE URNI]D CI{ECKS WILL BE SUBJECT TO A $25 FEE. IT IS YOUR RESPOSIBILIT'YAS T'I{E PAT]ENT TO NOTIF'Y THIS OFFICE OF ANY INSURANCE, PHONE OR ADDRESS

CHANGES IMMEDIATELY TO FACILITATE PROPER BILLING.

I understand the above information and am aware at anytime I may request a full copy of theprivacy notice for the Las Vegas Medical Center

Patient Date

J