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  • Home
  • Our Services
    • Outpatient Office
    • Hospitals
    • Dialysis Units
    • Transplant Clinic
  • Patients
    • New Patients
    • Existing Patients
    • Make A Payment
  • Education
  • Referrals
  • Our Providers
  • Home
  • Our Services
    • Outpatient Office
    • Hospitals
    • Dialysis Units
    • Transplant Clinic
  • Patients
    • New Patients
    • Existing Patients
    • Make A Payment
  • Education
  • Referrals
  • Our Providers

New Patient Forms Packet

Home / New Patient Forms Packet

New Patient Forms Packet

Step 1 of 5

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Basic Information & Patient Consent

Name(Required)
Date of Birth(Required)
Address(Required)
Sex(Required)
Race(Required)

Ethnicity(Required)
Language(Required)

Marital Status(Required)
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Spouse's Information

Spouse's Name(Required)
Date of Birth(Required)

Emergency Contact Information(Required)
Name
Phone
Relationship
 
A maximum of 2 emergency contact persons only.

Primary Care Physician(Required)
Address(Required)

CONSENT FOR ROUTINE MEDICAL TREATMENT: Nephrology Specialists of Oklahoma and its employees are hereby authorized to collect medical history information; obtain vital signs and perform other routine procedures for the purpose of providing care to you. You have the right to consent or refuse consent to any proposed procedure or therapeutic course, absent emergency, or extraordinary circumstances. Under emergency circumstances, we will take necessary and available actions to meet your medical needs.
(Required)
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Insurance Information

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Policy Holder Name(Required)
Date of Birth(Required)
Do you have a secondary Insurance?(Required)

Secondary Insurance

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Policy Holder Name(Required)
Date of Birth(Required)

Is your insurance Indian Health?(Required)
Is your insurance TRICARE, CHAMPUS, or CHAMP VA?(Required)
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Section Break

Sponsor Name(Required)
Date(Required)

Insurance Authorization and Assignment of Benefits

As consideration for the services provided to you, you guarantee payment for any amounts due for such services provided by Nephrology Specialists of Oklahoma. Charges for services and goods shall be at Nephrology Specialists of Oklahoma billed charges rates unless otherwise agreed to in writing by Nephrology Specialists of Oklahoma. I hereby assign to Nephrology Specialists of Oklahoma all payments for medical services rendered to myself or my dependents. I understand that I am responsible for amounts not covered by insurance. I further understand that it is my responsibility to notify Nephrology Specialists of Oklahoma of all address, phone number, and insurance information changes. Medicare recipients are responsible for 20% of allowed charges, deductibles, and co-insurance amounts. Other insurance patients are responsible for their co-payments and deductible at the time of service.(Required)
As consideration for the services provided to you, you guarantee payment for any amounts due for such services provided by Nephrology Specialists of Oklahoma. Charges for services and goods shall be at Nephrology Specialists of Oklahoma billed charges rates unless otherwise agreed to in writing by Nephrology Specialists of Oklahoma. I hereby assign to Nephrology Specialists of Oklahoma all payments for medical services rendered to myself or my dependents. I understand that I am responsible for amounts not covered by insurance. I further understand that it is my responsibility to notify Nephrology Specialists of Oklahoma of all address, phone number, and insurance information changes. Medicare recipients are responsible for 20% of allowed charges, deductibles, and co-insurance amounts. Other insurance patients are responsible for their co-payments and deductible at the time of service.
You agree that all insurance benefits for Nephrology Specialists of Oklahoma charges payable for the insured are to be made payable to Nephrology Specialists of Oklahoma and that insurance benefits for services provided by physicians in the practice setting, otherwise payable to the insured are to be made payable to the physician(s) responsible for your care. Any payment received for this episode of care may be applied to any unpaid bills for which you are liable, subject to the rules of coordination of benefits. PATIENT'S CERTIFICATION: I hereby certify that I have read each of the above statements and that I am the patient or legally authorized representative to accept the terms of this patient agreement and may receive a copy of this patient agreement.(Required)
You agree that all insurance benefits for Nephrology Specialists of Oklahoma charges payable for the insured are to be made payable to Nephrology Specialists of Oklahoma and that insurance benefits for services provided by physicians in the practice setting, otherwise payable to the insured are to be made payable to the physician(s) responsible for your care. Any payment received for this episode of care may be applied to any unpaid bills for which you are liable, subject to the rules of coordination of benefits. PATIENT'S CERTIFICATION: I hereby certify that I have read each of the above statements and that I am the patient or legally authorized representative to accept the terms of this patient agreement and may receive a copy of this patient agreement.
I hereby certify that I have read each of the above statements and that I am the patient or legally authorized representative to accept the terms of this patient agreement and may receive a copy of this patient agreement.(Required)
I hereby certify that I have read each of the above statements and that I am the patient or legally authorized representative to accept the terms of this patient agreement and may receive a copy of this patient agreement.
Unless other arrangements were made with our office prior to services.(Required)
Unless other arrangements were made with our office prior to services.
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Pharmacy & Medication Information

Address

Address

Is this a Medicare Part D Plan?

List all prescription, medications, including aspirin, laxatives, cough medications, birth control, etc.
Name
Dose
Frequency
Last Dose
 
To add new list please click the "+" plus icon on the right side.
Do you have any allergies?

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Pre-Visit Questionnaire

History

How long have you known about your kidney dysfunction?(Required)
Has your doctor (or other healthcare provider) informed you of a specific diagnosis?(Required)
Have you suffered from high blood pressure?(Required)
For how long?(Required)
Is there a family history of high blood pressure?(Required)
Have you been treated for this condition?(Required)
Have you ever experienced a stroke?(Required)
Is there a family History of high blood pressure?(Required)
Have you ever experienced a heart attack?(Required)
Do you have diabetes mellitus?(Required)
For how long?(Required)
Is there a family history of diabetes mellitus?(Required)
Have you been treated for this condition ?(Required)
Do you suffer from symtoms of neuropathy(e.g numbeness, tingling, shooting pains in either or both the upper and lower extremities)(Required)
Have you recieved lase treatments foe diabetic eye diseases(retinal bleeding)?(Required)
Do you have symptoms of nausea, vomiting, or diarrhea?(Required)
Do you have systemic lupus erythematosus (SLE), scleroderma, or any auto-immune diseases?(Required)
Have you used nonsteroidal anti-inflammatory drugs(NSAID) such us Ibuprofien, Motrin, Advil, Aleve, Celebrex, Lodine, Voltaren, etc, for prolonged periods of time? IF yes, please describe(Required)
Have you experienced kidney stones?(Required)
Have you had frequent urinary tract infections?(Required)
Have you been exposed to either chemicals solvents or heavy metals for prolonged periods of time?(Required)
Do you notice foaming of the water in the toilet bowl after urinating?(Required)
Do you have trouble starting, maintaining or completing urination?(Required)
Have you ever noticed bright red blood in your urine?(Required)
Do you currently smoke?(Required)
Have you smoked in the past?(Required)
Is there a family history of kidney disease?(Required)

Previous Diagnoses & Surgical Procedures

Have you had any previous operations or surgical procedures?(Required)
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AUTHORIZATION FOR ACCESS OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

If you would like Nephrology Specialists of Oklahoma to be able to talk in person or on the phone to anyone including your spouse or family members regarding your appointments, medical results, or provide any medical information, you will need to list them below.

I hereby authorize the use or disclosure of the Protected Health Information described below to be provided to or obtained by the following:

Name of Individual/Facility/Company to receive Protected Health Information

Name(Required)
Name
Address(Required)
Address

Information authorized for use or disclosure, or to be obtained:(Required)
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I understand that I may revoke this authorization at any time, in writing, except revocation will not apply to information already used or diclosed to this authorization. I may revoke this document by presenting my written revocation as provided in the Notice of Privacy Practices.

NOTICE OF PRIVACY PRACTICES

CONSENT OF DISCLOSURE OF IN INFORMATION: Patient medical records and billing information are created and retained by Nephrology Specialists of Oklahoma and are accessible to its personnel and medical staff for use in your care. Nephrology Specialists of Oklahoma and physicians may use and disclose medical information for its business operations and to any other physician or health care personnel involved in providing care. Safeguards are in place to dicourage improper access. Nephrology Specialists of Oklahoma is authorized to disclose all or part of my medical record to any insurance carrier, worker's conpensation carrier, or administrator of a self-insured employer group which is responsible for any part of Nephrology Specialists of Oklahoma's charges and to any health care provider who is or is expected to become involved with a patient's care. These disclosures are for treatment or payment purposes. The information authorized for release may include records which may indicate the presence of a communicable or non communicable disease. You understand that your medical information may indicate that you have or have been treated for psychological or psychiatric conditions or substance abuse. By signing this agreement, you are consenting to such disclosure. You may revoke this consent in writing, addressed to Nephrology Specialists of Oklahoma, except to the extent er have already acted in reliance on it.

A complete description of how your medical information will be used and disclosed by Nephrology Specialists of Oklahoma is in our NOTICE OF PRIVACY, which can be given to you by Nephrology Specialists of Oklahoma at your request.

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This field is for validation purposes and should be left unchanged.

Our philosophy is a patient centric approach. We take care of the whole patient and their kidney disease.

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Yale Office

  • 6465 South Yale Ave Suite 507 Tulsa, OK 74136
  • (918) 712-5000

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  • 1145 South Utica Ave Suite 364 Tulsa, OK 74104
  • (918) 712-5000

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