Kiest Park Medical Clinic
2225 Vatican Lane
214-333-3393
Dr. Louis Zegarelli
Dallas, TX 75224
FAX: 214-333-0809
Smart Living Medical Center
4230 W Green Oaks Blvd Arlington, TX 76016
817-200-7533 FAX: 8117-476-6051
PLEASE PRINT CLEARLY
Primary Insurance Co. __________________________________
Name _______________________________________________
Plan Name ___________________________________________
If married, Maiden Name _______________________________
Plan Type ____________________________________________
Social Security # ______________________________________
Group Name _________________________________________
Date of Birth month __________ day __________ year ______
Group # _____________________________________________
Marital Status (circle one) married
Policy # (ID #) ________________________________________
Gender male
female
single
domestic partner
Race __________________
Ethnicity _____________ Languages spoken ______________
Start/Effective Date ___________________________________
Office Copay $_____________________
Lawyer’s Name ______________________________________
Home address ________________________________________
Phone _______________________________________
City _______________ State ________ Zip_________
Mailing Address (if different) ____________________________
City________________ State ________ Zip ________
The reason for my visit today is: (circle one)
Medical
Auto accident
Worker’s Comp
Other
Home Phone (_______) _______________________________
Mobile Phone (_______) _______________________________
Work Phone
(_______) _______________________________
Have you had the following:
NO
WANT IT
Flu shot
_____
________
Personal email _______________________________________
Pneumonia shot
_____
________
Pharmacy ____________________________________________
Hepatitis B Vaccine
_____
________
Shingles vaccine
_____
________
Other _____________
_____
________
Phone ________________________________________
Who referred you to Dr. Zegarelli?
_____________________________________________
Responsible Party on this account self
other _____________
If Other: Name ________________________________
Relationship to Patient __________________________
Mailing Address _______________________________
City _______________ State ________ Zip _________
Phone (________) ______________________________
Email ________________________________________
Emergency Contact
responsible party other
If Other: Name ________________________________
Relationship to Patient __________________________
Mailing Address _______________________________
City _______________ State ________ Zip _________
Phone (________) ______________________________
Email ________________________________________
List the medications you are taking:
Prescription:
____________________________ Dose ____________
____________________________ Dose ____________
____________________________ Dose ____________
____________________________ Dose ____________
____________________________ Dose ____________
Over the Counter:
____________________________ Dose ____________
____________________________ Dose ____________
____________________________ Dose ____________
Vitamins/Herbs/Minerals/Other:
____________________________ Dose ____________
____________________________ Dose ____________
____________________________ Dose ____________
____________________________ Dose ____________
Current Problems:
(Please list all current problems you are experiencing. List the
most severe first, the second most severe next, etc.)
Date of Onset
______________
Do you use tobacco?
Do you drink alcohol?
YES
YES
YES
So you practice safe sex?
YES
Have you had exposure to STDs?
YES
YES
Do you keep firearms in
your home?
Do you wear seatbelts?
Do you have, or have you ever had, any of the following?
______________________________
6.
Does your home have
Smoke detectors?
______________________________
5.
______________________________
4.
______________________________
3.
______________________________
2.
Problem
______________________________
1.
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
______________
______________
______________
______________
______________
(check all that apply)
head trauma
blindness, cataract, glaucoma
trouble hearing, hearing aids
allergic rhinitis, sinus infections
dentures
heart problems, angina, murmur
high blood pressure, low blood pressure
aneurysm
asthma
bronchitis, pneumonia, COPD, emphysema
cirrhosis, gallbladder disease
GERD, Heartburn, hiatal hernia, ulcer
hepatitis, jaundice
hemorrhoids
hernia
incontinence
kidney disease, UTI
STDs
arthritis, gout, muscular injury, skeletal injury
dermatitis, moles, psoriases
epilepsy, seizures
stroke, TIA
severe headaches, migraines
bipolar disorder
depression
hallucinations, delusions
thoughts of suicide, suicide attempts
goiter
cholesterol problems, thyroid problems
high blood sugar, diabetes, low blood sugar
anemia
cancer
HIV
TB
Other _________________________________________
Surgeries:
Type
__________
_____________________________
__________
_____________________________
Length of Stay
___________
___________
___________
Reason
_______________________
_______________________
_______________________
YES
Do you take daily aspirin?
YES
Do you regularly exercise?
YES
Do you eat healthy meals?
YES
Do you use illicit drugs?
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
If female:
Date of onset of last mensus __________________
Have you ever been pregnant? _________________
Have you given birth? _______________________
Have any of your family had any of the following?
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
arthritis
asthma
bleeding disorder
heart disease
diabetes
high cholesterol
hypertension
lung disease
mental illness
osteoporosis
stroke
Cancer if yes, what type?
_________________________________________
other ____________________________________
List all allergies (if none, check the blank below):
____ No known allergies
Medications _______________________________
Foods ____________________________________
Year
__________
_____________________________
Hospitalization History:
Year
_____
_____
_____
Other ____________________________________
I acknowledge that I have been
provided KPMC’s
Notice of Privacy Practices
Date
Signature of Patient or Personal Representative
____
________________________________
Kiest Park Medical Clinic
2225 Vatican Lane
214-333-3393
Dallas, TX 75224
FAX: 214-333-0809
Dr. Louis Zegarelli
Smart Living Medical Center
4230 W Green Oaks Blvd Arlington, TX 76016
817-200-7533 FAX: 8117-476-6051
Name ___________________________________________________________ Date _____________________________________
No Show and Cancellation Policy
I understand that if I fail to show up for my appointment without 24 hours notice I may be subject to a “No Show” fee that is not billable
to insurance. I also understand that if I fail to show up for my appointment without notice of cancellation 3 times, any future appointments will be made when the appointment is pre-paid. This is non-refundable and will NOT be credited to future appointments.
Financial Policy
I understand that charges incurred for services rendered by Kiest Park Medical Clinic or Smart Living Medical Center are my responsibility, regardless of insurance coverage. I understand and agree that insurance policies are an agreement between the insurance carrier
and me; and not between my insurance carrier and Kiest Park Medical Clinic or Smart Living Medical Center. Furthermore, I understand KPMC/SLMC will prepare any necessary reports and forms to assist in making collections from my insurance company and that
any amount authorized to be paid directly to KPMC/SMLC will be credited to my account upon receipt.
Assignment will be accepted for all insurance with which KPMC/SMLC participates. It is my responsibility to provide this office with
accurate insurance information and to notify KPMC/SLMC of any changes in health insurance coverage. If I have any questions on network status/participation with my insurance , it is my responsibility to contact the customer service number on my insurance card.
I understand if any insurance company sends a check or reimbursement to me; THE CHECK DOES NOT BELONG TO ME. I am to
bring the check and Explanation of Benefits to KPMC/SMLC.
Patient Responsibility:
If my insurance has an office co-payment, co-insurance, or deductible that has not been satisfied, I must pay this at the time of my appointment. I understand that charges for professional services rendered are due and payable immediately. Any amount unpaid by my
insurance company is my responsibility and is due immediately upon notification of the denial by my insurance company. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. All cost
for my care is my responsibility. I agree that I will be responsible for all attorney and legal fees if legal action becomes necessary to
collect.
Billing: Know your insurance policy
I understand that I am responsible for any rejected claims, non-covered expenses, deductibles, co-insurance/copayments. Cash, money
order, Visa and Master Card are acceptable means in which to pay the balance.
I understand that at times, no matter how diligent KPMC/SLMC’s billing might be, my insurance company might decline a claim for
services. In that event, it is most effective for me to contact the insurance company since I am their paying customer. KPMC/SLMC’s
billing department will be glad to assist me, but I may be asked to intervene as that is the most effective means of settling disputes with
my insurance company.
If there remains an unpaid balance and I make no payment or make no contact as the responsible party despite all KPMC/SLMC’s efforts to contact me, then my account could be turned over to a collection agency or pursued legally.
Informing our patients about our financial policy assists us in providing the best service to our patients.
Thank you for taking the time to read this policy statement.
Should you have further questions or comments, please kindly contact our Business Office Supervisor.
I hereby understand the financial policy of this practice. I guarantee payment of all charges incurred for the account of the patient named
below. I further agree to pay any attorney’s fees, court costs, and related collection fees incurred. I also agree that my employer may be
contacted to verify employment status.
Patient name/Signature ____________________________________________________________ Date _________________________
Guarantor/Responsible Party Signature _______________________________________________ Date _________________________
Kiest Park Medical Clinic
2225 Vatican Lane
214-333-3393
Dallas, TX 75224
FAX: 214-333-0809
Dr. Louis Zegarelli
Smart Living Medical Center
4230 W Green Oaks Blvd Arlington, TX 76016
817-200-7533 FAX: 8117-476-6051
Kiest Park Medical Clinic
2225 Vatican Lane
214-333-3393
Dallas, TX 75224
FAX: 214-333-0809
Dr. Louis Zegarelli
Smart Living Medical Center
4230 W Green Oaks Blvd Arlington, TX 76016
817-200-7533 FAX: 8117-476-6051
Kiest Park Medical Clinic
2225 Vatican Lane
214-333-3393
Dallas, TX 75224
FAX: 214-333-0809
Dr. Louis Zegarelli
Smart Living Medical Center
4230 W Green Oaks Blvd Arlington, TX 76016
817-200-7533 FAX: 8117-476-6051
Patient Release of Medical Records Form
(Please Print or Type)
To:
Name of Clinic/Physician
_________________________________________________
Address
_________________________________________________
Phone#
_________________________________________________
Fax #
_________________________________________________
Patient's Name:__________________________ request and give my permission to release my
Medical Records for the time period dating from_________________ to _________________
The Medical Records as listed above are to be released to:
Dr. Louis Zegarelli
4230 W Green Oaks Blvd
Arlington, TX 76016
817-200-7533
Fax: 817-476-6051
Printed Patient Name
_________________________________________________
Date of Birth
_________________________________________________
Social Security #
_________________________________________________
Patient’s Signature
_________________________________________________
Today's Date
_________________________________________________