Medcorps Patient Form
Medcorps Patient Form
Medcorps Patient Form
It is our goal
to assist you with all of your pulmonary and sleep apnea needs. We
want to make your visit informative, productive and rewarding. During
your consultation, we will review your medical history, perform and
physical exam and discuss your goals. We encourage you to make a list
of questions you may have.
Before your appointment, please complete and return all paper work
from our office, provide us with any previous chest x-ray, PFT, sleep
study reports and any previous medical record from other providers that
will help us assist you at .your office visit.
901 Route 168 Suite 108, Turnersville NJ 08012 www.medcorpsusa.com 222 New Rd Suite #201, Linwood, NJ 08221
(856) 352-6572 - office (856) 352-6710 - fax (609) 788-8953 - office (609) 904-6929 - fax
MedCorps Asthma & Pulmonary Policies
Refill Policy
At your scheduled office visit, the provider will discuss appropriate monitoring
intervals. for your medications and any blood work that is required.
Most medications will be given 5 refills. Please let us know if you would like a
90day supply.
Patients should have been seen as indicated by their provider before a refill is
given, however a one-month courtesy prescription refill may be given as long as
the patient understands they need to be seen and/or complete blood work
before another refill will be issued.
Pre-authorization
Our office will complete any pre-authorization paperwork required by your
insurance company in a timely manner. We will call you when we know your
insurance company's decision regarding the medication, test or procedure.
901 Route 168 Suite 108, Turnersville NJ 08012 www.medcorpsusa.com 222 New Rd Suite #201, Linwood, NJ 08221
(856) 352-6572 - office (856) 352-6710 - fax (609) 788-8953 - office (609) 904-6929 - fax
MedCorps Asthma & Pulmonary Policies Continued:
Cancellation Policy
Please call at least 24 hours before your office visit to cancel an
appoin1ment. You may be assessed a missed appointment fee if you cancel
on the same day as your appointment or you miss an appointment
completely. Missed appointment fee is $50.00
Insurance Claims/Billing
MedCorps Asthma and Pulmonary Specialist participates with most major
insurance carriers. As a courtesy to our patients, we will file insurance claims
for those insurances with which we participate. Please remember, any
amount not covered by insurance is ultimately the patient's responsibility.
We require that you bring your insurance card and photo ID to all visits.
Payment
Payment will be requested at the time of service for all services that are
non-covered or determined to be the patient's responsibility, including
co-payments and deductibles from care you received at a rehabilitation
facility. Payment may be made by cash, check, MasterCard, or Visa. If you
have a question regarding insurance, billing or our fees, please call the office.
Patients name:
Patients signature:
Todays date:
901 Route 168 Suite 108, Turnersville NJ 08012 www.medcorpsusa.com 222 New Rd Suite #201, Linwood, NJ 08221
(856) 352-6572 - office (856) 352-6710 - fax (609) 788-8953 - office (609) 904-6929 - fax
MEDICATION LIST
Patients Name:
List any medications you are taking. Include both prescription and over-the -counter drugs,
inhalers and nebulized medications, oxygen as well as any regularly.
Name of Medication Dose {number of puffs or Pills Frequency (number of times per day)
Medications you have at home for a breathing exacerbation (e.g. antibiotics, steroids)
901 Route 168 Suite 108, Turnersville NJ 08012 www.medcorpsusa.com 222 New Rd Suite #201, Linwood, NJ 08221
(856) 352-6572 - office (856) 352-6710 - fax (609) 788-8953 - office (609) 904-6929 - fax
FAMILY HISTORY
Patients Name:
Allergies
Asthma
Blood Clots
Cancer
COPD
Emphysema
Heart Problems
Sleep Apnea
Restless Leg
Syndrome
901 Route 168 Suite 108, Turnersville NJ 08012 www.medcorpsusa.com 222 New Rd Suite #201, Linwood, NJ 08221
(856) 352-6572 - office (856) 352-6710 - fax (609) 788-8953 - office (609) 904-6929 - fax
MEDICAL RECORDS RELEASE Todays Date:
I, the undersigned, authorize the release of, or request access to the information specified below from the medical records of the
above named patient.
Requesting provider:
I understand that my records are confidential and cannot be disdosed without my written consent, except when otherwise permitted by law.
Information used or disclosed prior to this authorization may be subject to re-disclosure by the recipient and no longer protected. I understand
that the specified information to be released may indude but is not limited to history, diagnoses, and/or treatment of drug/alcohol abuse, mental
illness, or communicable disease.
I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the
authorization. This authorization will expire in 12 months from date of my signature, unless 1 revoke the authorization prior to that time.
901 Route 168 Suite 108, Turnersville NJ 08012 www.medcorpsusa.com 222 New Rd Suite #201, Linwood, NJ 08221
(856) 352-6572 - office (856) 352-6710 - fax (609) 788-8953 - office (609) 904-6929 - fax
The ERWORTH SLEEPINESS SCALE
(To access the risk of Obstructive Sleep Abnea )
Patients Name:
Use the following scale to choose the most appropriate number for each situation.
Chance of Dozing
Situation
Watching TV
TOTAL 0
Score:
10-12 Borderline
12-24 Abnormal
901 Route 168 Suite 108, Turnersville NJ 08012 www.medcorpsusa.com 222 New Rd Suite #201, Linwood, NJ 08221
(856) 352-6572 - office (856) 352-6710 - fax (609) 788-8953 - office (609) 904-6929 - fax