NEW PATIENT REGISTRATION

METROPLEX PULMONARY & SLEEP CENTER, P.A
4833 Medical Center Drive, Suite 6B McKinney, Texas 75069
Phone: 972- 838-1892 Fax: 972-838-1896 or 972-954-6030
Patient Registration
Name*
First Middle Last
Date of birth:*
Address:
State:
Zip:
Email address:*
Cell phone #:
Home Phone #
Work Phone#
Marital status:
Spouse’s name:
Emergency contact name:
Phone #
Relation:
Which is the best number to contact you?
Can we leave a message on your voice mail?
- Yes
- No
You can request your medical records to be mailed to your house. We will send those to you by USPS Certified mail and with signature confirmation. However, you must send us a written and signed request if you wish to receive your medical records via email.
Who do you authorize to talk to us on your behalf in your absence?
Name
First Middle Last
Relation:
Your Pharmacy’s name:
Phone number
Your oxygen and/or CPAP machine supplier’s name:
Phone number
INSURANCE INFORMATION
Primary Insurance Company:
Name of insured:
Group #:
ID #:
Secondary/Supplemental Insurance:
Name of Insured:
Group #:
ID #
Tertiary/Supplemental Insurance:
Name of Insured:
Group#:
ID #:
ASSIGNMENT OF INSURANCE BENEFITS
I request that payment of authorized insurance benefits be made on my behalf to Metroplex Pulmonary and Sleep Center for any services furnished by the provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration, and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.
Signature of Patient:
Or Authorized Representative:
Date:*
MM slash DD slash YYYY
Acknowledgement
METROPLEX PULMONARY & SLEEP CENTER, P.A
4833 Medical Center Drive, Suite 6B McKinney, Texas 75069
Phone: 972- 838-1892 Fax: 972-838-1896 or 972-954-6030
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Patient Name:*
Date of Birth:*
I acknowledge that Metroplex Pulmonary and Sleep Center provided me with a written copy its Notice of Privacy Practices.

I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.
Patient Signature*
Date*
Personal Representative Signature (if applicable)
Relationship to Patient
Sleep and breathing disorders are extremely common in this country and affect daytime wakefulness to different degree in each person. Obviously, each person must use his or her best judgement to be safe during operating heavy machinery, behind the wheel or working at heights. Furthermore, you should also be aware that sleep medications may cause daytime drowsiness as well. Therefore, you should not expose yourself to others to avoid possible harm due to potential drowsiness.
For your protection we require that you have received this notice. Therefore, please sign below.
Signature of Patient:*
Date*
Patient is responsible for the services
METROPLEX PULMONARY & SLEEP CENTER, P.A
4833 Medical Center Drive, Suite 6B McKinney, Texas 75069
Phone: 972- 838-1892 Fax: 972-838-1896 or 972-954-6030
Patient is responsible for the services/provided charges if insurance does not cover.
It is necessary for our office to enact the following policies effective January of each year due to the increase in high deductibles, co-insurance portions, co-payments of insurance companies’ pending claims and withholding payments. Please feel free to ask for clarification if necessary.

Your office visit, PFT Pulmonary Function (breathing) Test, sleep study take home device, Labs (orders sent out), CPAP, or CPAP Supplies and Spirometry might not be paid by your insurance. I hereby give authorization to Dr. Shahrukh Kureishy/Dr. Ferzana Mir and their staff to provide medical treatment. I understand that no guarantees have been made with regards to treatment success, and that there may be complications associated with the condition or with its proposed treatment. By signing below you are agreeing to pay for these services yourself, even if those are determined by your insurance as not to be “medically necessary.”

We ask for your insurance information when we schedule your first appointment, and we make every effort to verify your benefits for procedures that are common in our practice. While we do our best to verify that our doctors are contracted and in network with your insurance plan, it is ultimately your responsibility that this is the case. Based upon information provided to us by your insurance company we will expect payment according to the benefits quoted. Your copayment, co-insurance or deductible per your insurance company, and as indicated on most insurance cards will be collected before seeing the doctor. We will then file your office visit superbill with your insurance company. However, you will be responsible for your portion after your insurance pays, and as it indicates on your EOB. Also, we will not be held responsible if you or your accompanied person/s falls and injures in or outside our office. Any outstanding balance will be due and payable upon receipt of the statement. Many insurance plans have a requirement that patients must provide additional information to them before they will pay your claim. When this is the case, your insurance company will inform us that they have “pended” your claim for additional information. If that happens, the full balance due on your visit becomes your responsibility. Once an insurance company “pends” a claim, there is nothing that our office can do to get the claim paid. It is completely your responsibility to contact your insurance company to provide them the needed information so your insurance company pays the claim within 30 days. Additionally, you must notify us at the time of service if your insurance plan, group, or policy number changes so we can file your claim precisely.
Visits that have been filed by us in a timely manner but denied by your insurance after 60 days will become your responsibility. Please remember that our office files to your insurance as a courtesy to you. It is important to remember that your insurance policy is a contract between you and the insurance company.

I also understand that failure to appear on scheduled follow up or new patient visit appointment may result in a delay in the diagnosis, and treatment of a potentially serious condition. We call in advance to remind an upcoming appointment, and/or reschedule if the appointment cannot be kept. However, we will not be held responsible for complications arising from missed appointments due to the patient’s noncompliance.
We reserve the right to charge $35 for missed appointment and no show not given (24 hours’ notice by the patient.) Returned checks for insufficient funds will be subjected to $35 fees as well. Payment is expected at the time of service.
Signature of Patient:
Patient’s Printed Name:*
Responsible person’s name if patient is unable to sign:
Date*
Authorization to Disclose Protected Health Information

Shahrukh A. Kureishy M.D
Metroplex Pulmonary & Sleep Center
4833 Medical Center Drive-6B
McKinney, TX 75069

Developed for Texas Health & Safety $ Code 181.154(d)
effective June 2013
Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information. Covered entities as that term is defined by HIPAA and Texas Health & Safety Code $ 181.001 must obtain a signed authorization from the individual or the individual’s legally authorized representative to electronically disclose that individual’s protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law. Covered entities may use this form or any other form that compiles with HIPAA, the Texas Medical Privacy Act, and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.
NAME OF PATIENT OR INDIVIDUAL
Name*
First Middle Last
OTHER NAME(S) USED
DATE OF BIRTH*
ADDRESS
CITY
STATE
ZIP
PHONE*
ALT.PHONE
EMAIL ADDRESS (Optional)
I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL’S PROTECTED HEALTH INFORMATION:
Person/Organization Name:
Address:
CITY
STATE
ZIP
PHONE
ALT.PHONE
WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?
Person/Organization Name:
Address:
CITY
STATE
ZIP
PHONE
ALT.PHONE
REASON FOR DISCLOSURE
(Choose only one option below)
- Treatment/Continuing Medical Care
- Personal Use
- Billing or Claims
- Insurance
- Legal Purposes
- Disability Determination
- School
- Employment
- Other
Other
WHAT INFORMATION CAN BE DISCLOSED?
Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some these items. If all health information is to be released, then check only the first box.
- All health information
- Physician’s Orders
- Progress Notes
- Pathology Reports
- History/Physical Exam
- Patient Allergies
- Discharge Summary
- Billing Information
- Past/Present Medications
- Operation Reports
- Diagnostic Test Reports
- Radiology Reports & Images
- Lab Results
- Consultation Reports
- EKG/Cardiology Reports
- Other
Other
Your initials are required to release the following information:
- Mental Health Records (excluding psychotherapy notes)
- Drug, Alcohol, or Substance Abuse Records
- Genetic information(including Genetic Test Results)
- HIV/AIDS Test Results/Treatment
EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reaching the age of majority; or permission is withdrawn; or the following specific date (optional):
MM slash DD slash YYYY
RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION”. I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected
SIGNATURE AUTHRIZATION: I have read this form and agree to the uses and disclosure of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occured prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code $ 181.154(c) and/or 181.154(c) and/or 45 C.F.R $ 164.502(a)(1). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.
SIGNATURE X
Signature of Individual or Individual’s Legally Authrozed Representative
DATE
MM slash DD slash YYYY
Printed Name of Legally Authorized Representative (if applicable):
If representative, specify relationship to the individual:
- Parent of minor
- Guardian
- Other
A minor individual’s signature is required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment (See, e.g., Tex. Fam. Code $ 32.003).
SIGNATURE X
Signature of Minor Individual
DATE
MM slash DD slash YYYY

NEW PATIENT REGISTRATION

Patient Registration

INSURANCE INFORMATION

ASSIGNMENT OF INSURANCE BENEFITS

Acknowledgement

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Patient is responsible for the services

Patient is responsible for the services/provided charges if insurance does not cover.

Authorization to Disclose Protected Health Information

NAME OF PATIENT OR INDIVIDUAL

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL’S PROTECTED HEALTH INFORMATION:

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?