John Chang, MD, FACP, FACG
Amir Awad, MD, FACP, FACG
Alfredo Mendoza, MD, FACP, FACG
11912 Sheldon Road - Tampa, FL 33626
4695 Van Dyke Road - Lutz, FL 33558
508 S. Habana Ave., Ste. 270 - Tampa, FL 33609
813.920.8882
f. 813.920.8883
AUTHORIZATION FOR EXAMINATION AND/OR TREATMENT
Patient’s Name:
Date:
___
Social Security #:
Date of Birth:
___
I,
, hereby authorize Dr. Chang and health care professionals to
examine/or render treatment. I understand that this may also include testing, venipuncture, urinalysis, x-rays and/or
other diagnostic procedures. I have had the procedure or test explained to me including its risks, benefits, and
alternative courses of treatment, and have had the opportunity to have all of my questions answered.
PATIENT INFORMATION FORMS
All professional fees are due at the time of service, unless previous arrangements are made.
1. Services are rendered to the patient, not the insurance company. As a courtesy, our office will file your
insurance if proper information is received.
a. You are required to pay your co-payments (HMO) at the time of visit.
b. For unpaid claims over 45 days, it is your responsibility to follow up with your insurance carrier, and
the balance due is considered due and payable.
2. It is your responsibility to notify our front desk staff of any insurance or address changes.
3. You will be responsible for any changes that occur if we are not notified.
PATIENT AUTHORIZATION
By signing this form below, I authorize the following:
1. I authorize the doctor to submit Medicate or other insurance claims using my signature on file below.
2. I authorize the release of any medical information necessary to process this assignment on the claim.
3. I authorize payment of medical benefits to be paid directly to the physician indicated above for services
described on the claim form.
FINANCIAL INFORMATION
Patients who carry any form of medical insurance should know that all services furnished are charged directly to
the patients and he/she is responsible for payment. We will prepare any necessary forms to assist in making
collections from your primary insurance company and will credit such collection to your account. You will also be
expected to pay any benefit proceeds from your insurance to this office. However, we cannot render services on
the assumption that your charges will be paid sorely by your insurance. Most misunderstandings about insurance
can be avoided if you understand what your policy provides. Many insurance policies pay according to a schedule
of benefits that is based on various criterions. Not all insurance will pay 100% of our charges. The patient is
responsible to pay all sums unpaid by insurance. The patient authorizes the release of any information required in
the course of treatment as necessary to file insurance claims.
Patient unable to sign
Signature of patient or responsible party
Date:
Printed name of patient or responsible party
Relationship to patient if responsible party
HEALTH HISTORY
Confidential
Patient Name_______________________________________________________________________Today’s
Date_______________
Age_________Date of Birth__________________________________Date of Last Physical
Exam____________________________
Reason for Today’s
Visit_______________________________________________________________________________________
SYMPTOM Check (√) symptom/s you currently have or have had in the past year.
GENERAL
GASTROINTESTINAL EYE,EAR,NOSE,THROAT
□Chills
□Appetite poor
□Bleeding gums
□Depression
□Bloating
□Blurred vision
□Dizziness
□Bowel changes
□Crossed eyes
□Fainting
□Constipation
□Difficulty swallowing
□Fever
□Diarrhea
□Double vision
□Forgetfulness
□Excessive hunger
□Earache
□Headache
□Excessive thirst
□Ear discharge
□Loss of sleep
□Gas
□Hay fever
□Loss of weight
□GI bleeding
□Hoarseness
□Nervousness
□Hemorrhoids
□Loss of hearing
□Sweats
□Indigestion
□Nosebleeds
□Nausea
□Persistent cough
□Rectal bleeding
□Ringing in ears
□Stomach pain
□Sinus problems
MUSCLE/JOINT/BONE
Pain, weakness, numbness in: □Vomiting
□Vision-Flashes
□Arms
□Hips
□Vomiting blood
□Vision-Halos
□Back
□Legs
□Feet
□Neck
□Hands
□Shoulders
CONDITIONS Check (√) conditions you have or have had in the past year.
□AIDS
□Chemical Dependency
□High Cholesterol
□Alcoholism
□Chicken Pox
□HIV Positive
□Anemia
□Diabetes
□Kidney Disease
□Anorexia
□Emphysema
□Liver Disease
□Appendicitis
□Epilepsy
□Measles
□Arthritis
□Glaucoma
□Migraine Headaches
□Asthma
□Goiter
□Miscarriage
□Bleeding Disorders
□Gonorrhea
□Mononucleosis
□Breast Lump
□Gout
□Multiple Sclerosis
□Bronchitis
□Heart Disease
□Mumps
□Bulimia
□Hepatitis
□Pacemaker
□Cancer
□Hernia
□Pneumonia
□Cataracts
□Herpes
□Polio
MEDICATIONS List medications you are currently taking
Pharmacy Name
Phone #
CARDIOVASCULAR
□Chest pain
□High blood pressure
□Irregular heart beat
□Low blood pressure
□Poor circulation
□Rapid heart beat
□Swelling of ankles
□Varicose veins
GENITO-URINARY
□Blood in urine
□Frequent urination
□Lack of bladder control
□Painful urination
SKIN
□Bruise easily
□Hives
□Itching
□Change in moles
□Rash
□Scars
□Sore that won’t heal
□Prostate Problem
□Psychiatric Care
□Rheumatic Fever
□Scarlet Fever
□Stroke
□Suicide Attempt
□Thyroid Problems
□Tonsillitis
□Tuberculosis
□Typhoid Fever
□Ulcers
□Vaginal Infections
□Venereal Disease
ALLERGIES to medications or substances
All information is strictly confidential
FAMILY HISTORY Fill in health information about your immediate family
Relation Age State of
Age at
Cause of Death
Check (√) if, your blood relatives had any of the following:
Health
Death
Disease
Relationship to
you
Father
Arthritis, Gout
Mother
Asthma, Hay Fever
Brothers
Cancer:
pancreatic, stomach, liver
Chemical Dependency
Diabetes
Heart Disease, Strokes
Sisters
High Blood Pressure
Kidney Disease
Tuberculosis
Other
HOSPITALIZATIONS
PREGNANCY HISTORY
Yr. of Sex of
Yeah
Hospital
Reason of Hospitalization & Outcome
Complications if any
Birth
Have you ever had a blood transfusion? □ Yes
□ No
If yes, please give approximate
dates__________________________________
Have you ever had hepatitis?
□ Yes □ No
If yes, what
type?_________________________________________________
SERIOUS ILLNESS/INJURIES
DATE
OUTCOME
Birth
HEALTH HABITS Check (√) which substances
you use & describe how much you use
Caffeine
Tobacco
Street Drugs
Other
OCCUPATIONAL CONCERTS Check (√) if
your work exposes you to the following:
Stress
Hazardous Substances
Heavy Lifting
Other
Your occupation:
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my doctor if I, or
my minor child, ever have a change in health.
____________________________________________________________________________________
______________________________________________
Signature of Patient, Parent, Guardian or Personal Representative
____________________________________________________________________________________
______________________________________________
Please print name of Patient, Parent, Guardian or Personal Representative
Date
Relationship to Patient
John Chang, MD, FACP, FACG
Amir Awad, MD, FACP, FACG
Alfredo Mendoza, MD, FACP, FACG
11912 Sheldon Road - Tampa, FL 33626
4695 Van Dyke Road - Lutz, FL 33558
508 S. Habana Ave., Ste. 270 - Tampa, FL 33609
813.920.8882
f. 813.920.8883
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES & PERMISSION TO SHARE HEALTH
INFORMATION.
I have received a copy of the Westchase Gastroenterology Notice of Privacy Practice this day.
Patient/Authorized Representative (Title) Signature:________________________________________________
Date:_____________________________________
____________Received, but refuses to sign
Staff Signature:______________________________________________________Date:___________________
NOTIFICATION OF FAMILY & FRIENDS
I hereby authorize _____________________to disclose my health information to the following persons:
Person to be notified (name, address, phone number)
1.________________________________________________________________________________________
2.________________________________________________________________________________________
3.________________________________________________________________________________________
Patient/Authorized Representative (Title) Signature:________________________________________________
Date:________________________________________
RISTRICTIONS ON THE USE & DISCLOSURE OF YOUR HEALTH INFORMATION
As further described in the Westchase Gastroenterology Notice of Privacy Practice, I understand that I may request certain
restrictions on the use and disclosure of my health information. I request the following restrictions. Westchase
Gastroenterology is not required to agree to my requests.
1.______________________________________________________________
_____YES_____NO
2.______________________________________________________________
_____YES_____NO
3.______________________________________________________________
_____YES_____NO
Patient/Authorized Representative (Title) Signature:________________________________________________
Date:______________________________
WESTCHASE GASTROENTEROLOGY
John Chang, MD, FACP, FACG
Amir Awad, MD, FACP, FACG
Alfredo Mendoza, MD, FACP, FACG
11912 Sheldon Road - Tampa, FL 33626
4695 Van Dyke Road - Lutz, FL 33558
508 S. Habana Ave., Ste. 270 - Tampa, FL 33609
813.920.8882
f. 813.920.8883
AUTHORIZATION TO RELEASE MEDICAL RECORDS
TO: Westchase Gastroenterology
John Chang, MD, FACP, FACG
11912 Sheldon Road, Suite B
Tampa, FL. 33626
OTHER:
___
___
___
Please provide a list of all physicians, hospitals or other agencies from whom you have received care or
treatment within the last (3) three years.
1. Name:
___
Address:
___
City
State:
Zip Code:
___
Phone or other contact information:
___
2. Name:
___
Address:
___
City
State:
Zip Code:
___
Phone or other contact information:
___
I permit a copy of this form be used in the place of an original
Patient’s Name:
Date:
/
/
Social Security #:
Birth Date:
/
/
I understand this consent is revocable upon the written notice of the facility, except to the extent that action by the facility has been
taken in reliance on this authorization and that this authorization shall remain in force for a six-month period in order to effect the
purpose for which it was given.
Alcohol and drug abuse information, if present, has been disclosed from records whose confidentiality is protected by Florida Law.
Federal regulations (42CFR, Part II), prohibit making any further disclosure of records without specific written authorization of the
undersigned, or otherwise permitted by such regulations.
The confidentiality of HIV antibody test results is protected by Florida Law (Fla.Stat.Ann. 381.609 (2)), which prohibits any further
disclosure by a person to whom this information has been disclosed, without specific written consent of the undersigned as
otherwise permitted by state law.
Patient unable to sign
Signature of patient or responsible party
Date:
___
Printed name of patient or responsible party
___
Relationship to patient if responsible party
Witness
New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or
Healthcare Operations
I, _________________________, understand that as part of my health care, Dr. Chang originates and maintains paper
and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment,
and any plans for the future care or treatment. I understand that this information serves as:
 A basis for planning my care and treatment
 A means of communication among the many health professionals who contribute to my care
 A source of information for applying my diagnosis and surgical information to my bill
 A means by which a third-party payer can verify that services billed were actually provided, and
 A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare
professionals
I understand and have been provided with Notice of Information Practices that provides a more complete description
of information uses and disclosures. I understand that I have the following rights and privileges:
 The right to review the notice prior to signing this consent
 The right to object to the use of my health information for directory purposes , and
 The right to request restrictions as to how my health information may be used or disclosed to carry out
treatment, payment, or health care operations
I understand that Dr. Chang is not required to agree to the restrictions requested. I understand that I may revoke this
consent in writing, except to the extent that the organization has already take action in reliance thereon. I also
understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as
permitted by Section 164.506 of the Code of Federal Regulations.
I further understand that Dr. Chang reserves the right to change their notice and practices and prior to implementation,
in accordance with Section 164.520 of the Code of Federal Regulations. Should Dr. Chang change their notice, they
will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or, if I agree, email).
I wish to have the following restrictions to the use or disclosure of my health information:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
____________________________________________
I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary
to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses,
including disclosures via fax. I fully understand and accept/decline the terms of this consent.
______________________________________________________________________________
Patient Signature
Date
FOR OFFICE USE ONLY
___ Consent received by__________________________on__________________
___ Consent refused by patient, and treatment refused as permitted.
___ Consent added to the patient’s medical record on_________________
John Chang, MD, FACP, FACG
Amir Awad, MD, FACP, FACG
Alfredo Mendoza, MD, FACP, FACG
11912 Sheldon Road - Tampa, FL 33626
4695 Van Dyke Road - Lutz, FL 33558
508 S. Habana Ave., Ste. 270 - Tampa, FL 33609
813.920.8882
f. 813.920.8883
Thank you for allowing us to be a part of your healthcare team. Please do not hesitate to
contact us if you have any questions.
Dr. John Chang and Staff
PATIENT REGISTRATION
NAME: (first)
(mi)
(last)
Date of Birth:
/
/
Age:
Gender:
Male
Female Martial Stature: S M D W
Social Security #:
Driver License #:
Address: (street)
City, State, Zip:
Home Ph: (
)
Cell: (
)
Work: (
)
Employer:
Occupation:
What is the best number to reach you?
Home
Work
Cell
Other (
)
Who may we thank for referring you to our office?
E-mail:
Would you like to be contacted via e-mail?
YES
NO
Responsible Party or Spouse Information
Name:
Relationship to Patient:
Social Security #:
Date of Birth:
/
/
Cell: (
)
Work: (
)
Employer:
Friend or Relative Not living with You:
Phone: (
)
In case of emergency who should be notified? (PLEASE LIST ONE CONTACT)
Name:
Relationship to Patient:
Ph #: (
)
Name:
Relationship to Patient:
Ph #: (
)
INSURANCE INFORMATION
Primary Insurance Company:
ID #:
Secondary Insurance Company:
ID#:
Is the insurance in you name?
Yes
No
IF INSURANCE IS NOT IN YOUR NAME, PLEASE COMPLETE THE FOLLOWING SECTION
NAME: (first)
(mi)
(last)
Date of Birth:
/
/
Social Security #:
.
Patient Signature
Date
NOTICE OF PRIVACY PRACTICES
Effective 4/07/2003
I hereby acknowledge that I have been presented with a copy of my doctor’s Notice of Privacy Practice. I
understand questions or complaints with regard to my privacy rights may be addressed by my contacting the practice
manager, my doctor, or the department of Health and Human Services.
______________________________________________
Patient or Authorized Representative Signature
______________________________________________
Printed Name of Patient or Authorized Representative
Date:_______________
___ Patient refused to sign
_____Patient is unable to sign because:___________________________________________
To our patients. This notice describes how health information about you (as a patient of this practice) may be used
and disclosed and how you can get access to your health information. This is required by the Privacy Regulations
created as a result of the Health Insurance Portability and Accountability Act of 1196 (HIPPA).
Our Commitment to your privacy
Our practice is dedicated to maintaining the privacy of your health information. We are required by law to
maintain the confidentiality of your health information.
We realized that these laws are complicated but we must provide you with the following important
information:
Use and disclosure of your health information in certain special circumstances
The following circumstances may require us to use or disclose your health information:
1.
To public health authorities and health oversight agencies that are authorized by law to collection
information.
2.
Lawsuits and similar proceedings in response to a court or administrative order.
3.
If required, to do so by law enforcement officials.
4.
When necessary to reduce or prevent a serious thereat to your health and safety or the health and safety of
another individual or the public. We will only make disclosures to a person or organization able to help
prevent the threat.
5.
If you are a member of U.S. or foreign military forces (including veterans) and if required by the
appropriate authorities.
6.
To federal officials for intelligence and national security activities authorized by law.
7.
8.
To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law
enforcement official.
For workers Compensation and similar programs.
Your rights regarding your health information
1.
Communications. You can request that our practice communicate with you about your health and related
issues in a particular manner or at a certain location. For instance, you may ask that we contact you at
home, rather than work. We will accommodate reasonable requests.
2.
You can request a restriction in our use or disclosure of your health information for treatment, payment or
health care operations. Additionally, you have the right to request that we restrict our disclosure of your
health information to only certain individuals involved in your care of or the payment for your care, such
as family members and friends. We are not required to agree to your request; however, if we do agree, we
are bound by our agreement except when otherwise required by law, in emergencies, or when the
information is necessary to treat you.
3.
You have the right to inspect and obtain a copy of the health information that may be used to make
decisions about you, including patient medical records and billing records, but not including
psychotherapy notes. You must submit your request in writing to your office and we are authorized by
HIPPA to charge twenty-five cents per page.
4.
You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long
as the information is kept by or for our practice. To request an amendment, your request must be made in
writing and submitted to our office. You must provide us with a reason that supports your request.
5.
Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You
may ask us to give you a copy of this Notice at any time.
6.
Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint
with our practice or with the Secretary of the Department of Health and Human Services. To file a
complaint with our practice, contact the Administrator. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
7.
Right to provide an authorization for other uses and disclosures. Our practice will obtain your written
authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.
Special section for minors and persons with guardians:
This notice also applies to minors and certain disabled adults. They enjoy the same basic privacy protections
for their health information. However, because by law they usually cannot make health care decisions for themselves,
a parent or guardian can make medical decisions on their behalf. Therefore, parents or guardians can authorize the use
and release of this medical information. Parents or guardians may also hold all rights listed in this notice including the
right to inspect and copy and the right to amend.
Changes to this notice:
We reserve the right to revise or change this Notice of Privacy Practices. We reserve the right to make the
new notice’s provisions effective for all patient health information that we maintain, including those created or
received by us prior to the effective date of this notice. The effective date is set forth on the first page.
If you have any questions regarding this notice or our health information privacy policies, please don’t hesitate
to ask anyone of our staff.