TEXAS PULMONARY CRITICAL CARE … plan to arrive 15 minutes ... (tuberculosis, diabetes ... This facility has on staff advanced practice providers to assist in the delivery of pulmonary

TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A.

Dr. Samer H. Fahoum

Dr. R. Roger Gleason, III

Dr. John W. Hollingsworth, II

Dr. Obinna I. Okoye

Dr. John T. Pender, Jr.

1201 Fairmount Avenue

Fort Worth, Texas 76104

Phone 817/335-5288

Fax 817/338-0927

TO OUR NEW PATIENTS

You have been scheduled to see one of our physicians. If you have seen any of our physicians in the past, please call

our office immediately and let us know. Please complete all of the enclosed information and bring it to your

appointment, along with your insurance cards and driver's license. Please plan to arrive 15 minutes prior to your

appointment. If you are unable to keep your appointment, please call our office as soon as possible, as this will allow

us to schedule another patient in that time slot. If you do not cancel your appointment at least 24 hours in advance,

you may be charged for your visit.

NOTE: If your insurance company is an HMO, Managed Care, or POS and requires a referral, it is the

responsibility of your primary care physician to obtain the initial referral. If you do not have your referral at the

time of your appointment, you will be rescheduled and/or responsible for the bill.

You must bring all chest x-rays and CT scans (on CD/DVD) of your chest (with reports) to your appointment. If you

fail to bring these, you may be rescheduled. We also ask that you bring all current medications with you to your

appointment.

Office visit fees, including tests, range from $100 to $600 and new patient appointments last approximately one

hour. Insurance copayment and any deductibles are required at the time of service. If you feel you have special

circumstances that prevent you from paying at the time of service, contact our office BEFORE your appointment.

Our physicians employ registered nurses who are specifically trained to handle your questions by telephone. This

helps increase the availability of medical advice without increasing the cost to our patients. Your physician will call

you personally if there is a question only he can resolve. The best time to call is between 8:30 and 10:30 a.m. The

nurse will return your call as soon as possible. However, often it is in the afternoon before the nurse returns your

call. We make every effort to return your call the same day it is placed. If you are experiencing an acute breathing

emergency, please inform the receptionist at the time of your call.

Prescription refills should be called in 24 hours before needing them. No refills will be made on weekends or

holidays.

Free parking is available in our adjacent lot. In addition, we have wheelchairs and back-up E-cylinders for oxygen in

case of an emergency.

***FOR YOUR INFORMATION***

Appointment Time: Appointment Date: Your Doctor is:

________________ ________________ ________________



Fort Worth, TX 76104

817.335.5288

DIRECTIONS:

Heading North/Southbound on I-35W, take the W Rosedale Street exit. Head west on Rosedale. Drive approximately

18 blocks. You cannot turn left on Fairmount from Rosedale going west. Either turn left on 6th Avenue, then right on

W Oleander Street, or make a U-turn on 8th Avenue and turn right on Fairmount. Park in the lot at the northeast corner

of W Oleander Street and Fairmount, just north of our building.

East/Westbound I-30, exit Summit/8th Avenue. Turn south on Summit. (Summit becomes 8th Avenue.) Turn left on W

Rosedale Street. Turn right on Fairmount Avenue. Park in the lot at the northeast corner of W Oleander Street and

Fairmount, just north of our building.


Instructions for Pulmonary Function Testing

Do not use inhalers or nebulizer medication for four hours prior to your breathing test. If you

experience severe shortness of breath and feel you need to use your medication, do so and call the office.

Please ask to speak with the staff in the Pulmonary Function Lab to inform them of your medication use.

Do not drink any carbonated beverages or ingest caffeinated food or drink for at least three hours prior to

testing.

Avoid eating a heavy meal two hours before testing.

Do not smoke for at least three hours prior to the breathing test.

Do not drink alcohol for at least four hours before the test.

Do not exercise 30 minutes before the test.

Wear loose, comfortable clothing that does not restrict your breathing.

Please inform the technician prior to testing if you have hearing loss or will need an interpreter on the day of

your breathing test. If you are not fluent in English, please bring a translator with you on the day of the test.

If you wear dentures, you will be asked to remove them during the test.

If you experience any chest pain, pressure, discomfort or severe shortness of breath on the day of your test,

please contact our office and ask to speak with the staff in the Pulmonary Function Lab. Your test may be

canceled or delayed due to these symptoms or may be performed with the physician’s consent.

We do not allow children in the Pulmonary Function Lab. Please make arrangements for the care of your

children while you are away.

You will be asked to empty your bladder before the procedure to optimize comfort.

If you have any questions, please call our office at 817-335-5288 and ask to speak with the staff in the

Pulmonary Function Lab.

Patient Name:

Testing Date and Time:


Your Pulmonary Function Testing is scheduled at the location selected below:


Fort Worth, TX 76104

817-335-5288

DIRECTIONS:

Heading North/Southbound on I-35W, take the W Rosedale Street exit.

Head west on Rosedale. Drive approximately 18 blocks. You cannot

turn left on Fairmount from Rosedale going west. Either turn left on

6th Avenue, then right on W Oleander Street, or make a U-turn on 8th

Avenue and turn right on Fairmount. Park in the lot at the northeast

corner of W Oleander Street and Fairmount, just north of our building.

East/Westbound I-30, exit Summit/8th Avenue. Turn south on Summit.

(Summit becomes 8th Avenue.) Turn left on W Rosedale Street. Turn

right on Fairmount Avenue. Park in the lot at the northeast corner of W

Oleander Street and Fairmount, just north of our building.

4375 Booth Calloway, Suite 402

North Richland Hills, TX 76180

817-284-4343

DIRECTIONS:

Major crossroads are Booth Calloway Road and West Pipeline

Road. We are on Booth Calloway north of West Pipeline.

You can get to the office from Booth Calloway and pull into

the parking lot in front of the Professional building or the new

Building. We are located in the new building to the right of the

Professional Building on the right, if you are facing west.

Come in the main entrance, go to the elevators to the fourth floor. Upon exiting the elevator, proceed to the right to suite

402.

911C Medical Centre Drive

Arlington, TX 76012

817-461-0201

DIRECTIONS:

Heading West on I-30, exit Cooper Street. Turn left at the

light. Turn right on Fuller. Fuller Street becomes Medical

Centre Drive. Our office is in the third group of office

buildings.

Heading East on I-30, exit North Fielder. Turn right at the

light. Turn left on Randol Mill. Turn right on Magnolia. Turn

left on Medical Centre Drive.

PATIENT __________________________________________________ DATE ________________________

PAST MEDICAL HISTORY

Please explain briefly why you are here to see the doctor: _______________________________________________

__________________________________________________________________________________________

List all ALLERGIES to food or drugs: _____________________________________________________________

CURRENT MEDICATIONS: (including inhalers)

Name of Medication Strength # times daily Length of Use

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Who does your insurance company require you to use for: Lab ____________________ X-ray__________________

Pharmacy_____________________________________________________ Phone __________________________

Date of last flu vaccine ______________________________ Date of last Pneumovax_________________________

SURGICAL HISTORY

What types of surgeries have you had in the past, and when? ____________________________________________

__________________________________________________________________________________________

Have you ever been hospitalized for anything other than the above surgeries? If yes, please explain. _____________

__________________________________________________________________________________________

Have you ever been diagnosed with any form of cancer? If yes, please explain. ______________________________ _____________________________________________________________________________________________

Have you ever had (please circle): High Blood Pressure Heart Trouble Diabetes Kidney Trouble

FAMILY HISTORY

Father: Living? No Yes Age: _____ Health problems or cause of

death:_______________________

---

Mother: Living? No Yes Age: _____ Health problems or cause of

death:_______________________

_

Brother: Living? No Yes Age: _____ Health problems or cause of

death:_______________________

Sister: Living? No Yes Age: _____ Health problems or cause of

death:_______________________

List any disease that "runs in the family" (tuberculosis, diabetes, cancer, heart disease, kidney trouble, mental illness,

stroke):_______________________________________________________________________________________

SOCIAL HISTORY

Do you drink alcohol? No Yes How much on a daily basis?_________________________________

Do you smoke cigarettes? No Yes How much on a daily basis?_________________________________

If no, have you ever smoked? No Yes When did you quit?_______ Packs/day_____ Number of years_____

Do you have pets? No Yes What kind?_______________________________________________

REVIEW OF SYSTEMS

Please indicate the symptoms you currently have or have had:

RESPIRATORY SYSTEM:

□ Productive/Nonproductive chronic cough

□ Blood in sputum

□ Asthma as a child

□ Pain in chest on deep breathing

□ Asthma or shortness of breath

□ Recurrent or frequent bronchitis

□ Snoring

□ Wheezing

□ Sarcoid

□ Positive TB skin test

□ Tuberculosis (TB)

□ Exposure to asbestos

□ Exposure to dust/fumes

□ Night sweats

CARDIOVASCULAR SYSTEM:

□ Palpitations

□ Swelling of feet

□ Sitting up in bed at night to get a good breath

□ Leg pain

□ Pain in chest going down into left arm

□ Awakening at night short of breath

GASTROINTESTINAL SYSTEM:

□ Poor appetite

□ Excessive gas

□ Vomiting

□ Nausea

□ Reflux/heartburn

□ Diarrhea

□ Bloody stools

□ Change in bowel habits

□ Jaundice

□ Hemorrhoids

□ Constipation

□ Use of laxatives

□ Difficulty swallowing

HEENT:

□ Swollen lymph nodes

□ Headaches

□ Dizziness

□ Failing vision

□ Spots before eyes

□ Watering of eyes

□ Itching of eyes

□ Frequent colds

□ Nose bleeds

□ Fever blisters

□ Sore tongue

□ False teeth

□ Trouble with sinuses

□ Hoarseness

□ Bleeding gums

□ Swelling of neck

□ Pain on moving neck

□ Goiter

□ Glaucoma

□ Cataracts

□ Thyroid

□ Hard of hearing

□ Postnasal drip

□ Seizures

MUSCULOSKELETAL SYSTEM:

□ Easy bruising or bleeding

□ Joint pain or stiffness

□ Muscle pain

□ Gout

□ Backaches

□ Weakness

□ Fractures

□ Restless legs

GENITOURINARY SYSTEM:

□ Pain on urination

□ Blood in urine

□ Swelling of face or hands

□ Surgery of prostate

□ Trouble starting stream

□ Frequent urination

□ AIDS


Advanced Practice Provider Consent

This facility has on staff advanced practice providers to assist in the delivery of pulmonary care.

These advanced practice providers are not physicians. They have received advanced education and training in

the provision of health care. Each can diagnose, treat, and monitor common acute and chronic diseases as well

as provide health maintenance care.

I have read the above and hereby consent to the services of an advanced practice provider for my health care

needs.

I understand that at any time I can refuse to see the advanced practice provider and request to see a physician.

Name Date

Signature

PATIENT REGISTRATION FORM Date:_______________________________

Patient Name Birth Date Sex SSN

Last First Middle

Are you currently residing in a skilled nursing facility? Yes No If yes, name of facility

Home Address

Street City State Zip+4

Home Phone Cell Phone Work Phone

Preferred contact method for reminders (select one or more):

Text (cell phone above) Voice message (circle preferred number above) Email (below) Do Not Contact

Email address I decline access to the portal

Patient Employer Employer Phone

Employer Address


Marital Status Religious Preference Patient Language

Ethnicity Latino/Hispanic Other Decline to Answer

Race American Indian or Alaskan Native Asian Asian Pacific American Black/African American

Caucasian (White) Hispanic More Than One Race Native American Native Hawaiian

Other Race Pacific Islander Subcontinent Asian American Unknown Decline to Answer

Spouse’s Name Spouse’s Employer

Spouse’s Work Phone Address

Referred By Phone Fax

Address


Primary Care Physician Phone Fax

Address


List other physicians you are currently seeing

Notify in case of emergency (Do not list anyone who lives with you)

Name Phone Relationship

Address


Have you signed a: Living Will: Yes No DNR (Do Not Resuscitate): Yes No (Please provide a copy)

Durable Power of Attorney: Yes No Date signed:_________________ (Please provide a copy)

Pharmacy Phone

Are you currently using a DME (Durable Medical Equipment) Company? Yes No

If yes, which one?

If no, who does your insurance company require you to use?

Who does your insurance company require you to use for: Lab X-ray

Is this a work-related illness/injury? Yes No Date of illness/injury Date last worked

Cause of accident, if any

I hereby authorize release of my medical records from_______________________________________________________to Texas

Pulmonary & Critical Care Consultants, PA.

Signature of Patient or Responsible Party Date

FINANCIAL POLICY

PRIMARY INSURANCE POLICY:

Insurance Co. ID No. Group No.

Name of Insured Insured’s DOB Ins Start Date

Relationship to Patient SSN Sex

Claims Mailing Address Co-pay

Phone No.

SECONDARY INSURANCE POLICY:

Insurance Co. ID No. Group No.

Name of Insured Insured’s DOB Ins Start Date

Relationship to Patient SSN Sex

Claims Mailing Address Co-pay

Phone No.

Responsible Party Name Phone Relationship

Address


Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy,

which we require you read and sign prior to any treatment. All patients must complete our Information and Insurance Form before

seeing the doctor. Full payment or copayment (if applicable) is due at the time of service. We accept cash, check, Visa, MasterCard,

Discover or American Express.

Regarding Insurance We cannot bill your insurance company unless you give us your insurance information. If we are nonparticipating with your insurance,

and they have not paid the balance within 90 days, the balance will be transferred to you. Please be aware that some, and perhaps all,

of the services provided may be non-covered services and/or not considered reasonable and necessary under the Medicare Program

and/or other medical insurance. These charges will be your responsibility. Our office makes every effort to obtain referral authorizations

from the Primary Care offices for patients on HMOs. Should we not be able to obtain a referral, charges will be your responsibility.

Out of Network Billing The physicians may not be participating physicians with your insurance plan, and if not, benefits may be reduced as such. You will be

responsible for any unpaid charges and/or balances. Our practice is committed to providing the best treatment for our patients and we

charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s (excluding

Medicare) arbitrary determination of usual and customary rates.

Missed Appointments Unless canceled at least 24 hours in advance, our policy is to charge for missed office and oximetry appointments at the rate of $25.00

and a separate charge for sleep testing at the rate of $200.00. Please help us serve you better by keeping scheduled appointments.


Research Consent I give permission for clinical and physiologic data from my medical records to be used for educational and research purposes. I

understand that my identity and contact information (name, SS#, birth date, address, etc.) will never be attached to or processed with

such data.


Appointment of Authorized Representative

Identifying Information

Patient’s name

Member’s name

Member’s address

Member’s plan identification #

Provider’s plan identification #

Service not paid / not authorized by plan

Date(s) of service

Appointment. I, , appoint Texas Pulmonary & Critical Care

Consultants, P.A. and/or Sleep Consultants, Inc. to act as my authorized representative in

requesting an appeal from in the event of denial of

services/denial of payment.

Directed payment. I agree that if the payment denial is overturned on appeal, the plan’s payment

should be paid directly to my authorized representative, and direct the plan to do so in that

event.

Member’s signature ____________________________ Date

Texas Pulmonary & Critical Care Consultants, P.A.

Sleep Consultants, Inc.

Acknowledgment of Review of

Notice of Privacy Practices

I have reviewed this office’s Notice of Privacy Practices, which explains how my medical

information will be used and disclosed. I understand that I am entitled to receive a copy of this

document.

__________________________________________

Signature of Patient or Personal Representative

__________________________________________

Date

__________________________________________

Name of Patient or Personal Representative

__________________________________________

Description of Personal Representative’s Authority

Texas Pulmonary & Critical Care Consultants, PA

Consent to release Protected Health Information (PHI)

I understand that in order to disclose my PHI, Texas Pulmonary & Critical Care Consultants, PA, must have my consent, therefore I

authorize Texas Pulmonary & Critical Care Consultants, PA to disclose my PHI as described in the provided forms to the recipients

listed below:

Description of the information to be disclosed (check all that apply)

☐All Procedures ☐Test Results ☐Appointments ☐Other ☐Surgeries ☐Billing/Account information

Name(s) of the person(s) authorized to obtain the above-mentioned information. (e.g. physician other than your referring doctor,

family members and other specified person/persons)

Name:____________________________________Relationship:_______________________________

Name:____________________________________Relationship:_______________________________

Contact Information:

I authorize Texas Pulmonary & Critical Care Consultants, PA to contact me at the following number with results or questions:

Home_____________________ Cell______________________ Work_______________________

May we leave a detailed message on your answering machine or voicemail?

Yes☐ No☐ Failure to check one of these boxes may delay results

By Patient: (print and sign)_________________________________________________________Date:_______________________

Or Patient’s Representative (print name, sign and describe authority)

__________________________________________________________________Date:___________________

Authorization expires one year from signature date.

In signing this HIPAA Patient Acknowledgement form, you acknowledge and authorize, that you hold harmless this Healthcare

Facility, its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring from

this authorization. I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law;

that this authorization remains effective until this Healthcare Facility is in actual receipt of a signed revocation or until the records

retention period required under federal and state law has expired and the records have been destroyed; that I have the right to revoke

this authorization at any time, provided I do so in writing; that I have been given the opportunity to ask questions; that I have received

a copy of the signed authorization; that I may inspect a copy of my PHI to be used or disclosed under this authorization; that this

Healthcare Facility has not conditioned provision of services to or treatment of me upon receipt of this signed authorization; and that I

may refuse to sign this authorization. A copy of this signed, dated Authorization shall be as effective as the original.

A copy of our Notice of Privacy Practices will be provided at your request.

Documents

TEXAS PULMONARY CRITICAL CARE … plan to arrive 15 minutes ... (tuberculosis, diabetes ... This facility has on staff advanced practice providers to assist in the delivery of pulmonary