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Steven M Pounders, MD, PLLC
3500 Oak Lawn, Suite 600
Dallas, TX 75219-4373

PATIENT INFORMATION UPDATE

Full Name *

Address *

Line 1

City *

Zip *

State *

Social Security Number *

Date of Birth *

Primary Phone *

Cell
Home
Work

Primary Phone *

OK to leave message? *

Secondary Phone

OK to leave message?

Email *

OK to leave message?

DEMOGRAPHICS

Race *

African American
Hispanic
Asian
Native American
Caucasian

Ethnicity *

Non-Hispanic
Hispanic
Refused

Preferred Language *

Preferred Pronouns

INSURANCE

Insurance Company *

Policy/Member ID# *

Group Number *

Are you the PRIMARY policy holder?

Multiple Choice *

(If YES, skip the next section. if NO, please fill out.)

POLICY HOLDER INFORMATION

Full Name

Address

Line1

City

State

Zip

Social Security Number

Date of Birth

EMERGENCY CONTACT INFORMATION

Please give the name of someone to contact in case of an emergency.

Name & Relation

Address

Line 1

Phone #

Name & Relation

Address

Address Line 1

Phone #

I authorize the release of any medical information necessary to process insurance claims. I authorize payment of medical benefits to Steven M. Pounders, MD, PLLC for services rendererd. If insurance denies payment, I agree to be personally and fully responsible for payment. I also authorize the release of medical records to any specialist(s) for any referring treatment/consult. I also understand that I may be charged a fee for missed appointments and cancellations with less than 24 hours notice; $50 for follow-ups and office visits, and $75.00 for a physical/wellness visit or procedure. An appointment is considered missed if I am not checked in at least 10 minutes after the appointment start time. I also may be charged a $35.00 fee for all insurance/disability related paperwork or physicians statements. Any additional costs involved in collecting an outstanding balance will be the sole responsibility of the patient.

Signature *

Date *

STEVEN M. POUNDERS, MD, PLLC
CONSENT TO USE AND DISCLOSE
PROTECTED HEALTH INFORMATION

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

Your protected health information will be used by Steven M. Pounders, MD, PLLC or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.

THE NOTICE OF PRIVACY PRACTICES

Steven M. Pounders, MD, PLLC is required to provide to you a notice that describes how information about you may be used and disclosed. Additionally, we must provide you information on how you may get access to this information. These policies and practices are defined in the “Notice of Privacy Policies and Practices” brochure provided to you. PLEASE REVIEW IT CAREFULLY.

YOU MAY PLACE RESTRICTIONS ON THE USE OR DISCLOSURE OF YOUR HEALTH INFORMATION

You may request a restriction on the use of disclosure of your protected health information. However, Steven M. Pounders, MD, PLLC may or may not agree to your request to restrict the use of disclosure of your protected health information. You may be asked to complete an authorization to activate this request. Please consult with a practice representative or the Office Manager if you would like additional information or clarification.

It is a violation of federal privacy standards if Steven M. Pounders, MD, PLLC agrees and fails to comply with your request. The restrictions requested will not affect use and disclosure of your information before the date of your request. If you still have questions after reviewing the Notice of Privacy Brochure, please consult with a practice representative or the Office Manager at the location and contact information listed on the back of the brochure.

YOU MAY REVOKE THIS CONSENT AT ANY TIME

You may revoke this consent at anytime; however, Steven M. Pounders, MD, PLLC requires that you must revoke this consent in writing. If you choose to revoke this consent, the revocation will not affect the use and disclosure of your information before the date of your request.

CHANGES TO PRIVACY PRACTICES

Steven M. Pounders, MD, PLLC reserves the right to change or modify the privacy practices outlined in the Notice of Privacy Brochure. Steven M. Pounders, MD, PLLC will notify you of any changes of privacy practices either by mail, at your next appointment, or any other pre-approved method that you request.

SIGNATURE

I have reviewed this consent form, received the brochure entitled “Notice of Privacy Policies and Practices” and give my permission to Steven M. Pounders, MD, PLLC to use and disclose my health information in accordance with this consent and the notice provided

Name of Patient:

Signature *

Date *

Date: MM/DD/YYYY

Patient Representative

Signature

Date

Date: MM/DD/YYYY

Relationship of Patient Representative to Patient

Signature

Date

Date: MM/DD/YYYY

STEVEN M. POUNDERS, MD, PLLC
Authorization of Use and Disclosure
of Protected Health Information

Appointment Reminders: The practice may use your information to remind you about upcoming appointments. Typically, appointment reminders are sent by e-mail that you have provided to the practice. Prior to your visit, our automated system also calls your phone and gives you a non-specific message that may be left on your answering machine. If you don’t approve of these methods and would like alternative reminder methods (i.e., text) please indicate those methods in the space provided.

How would you like to be contacted regarding appointments, treatment, and or other information pertinent to your healthcare for your healthcare provided at Steven M. Pounders, M.D., P.L.L.C.? You will automatically be notified by email of appointments. (Check all that apply)

Checkboxes *

Mobile Telephone
Home Telephone
Work Telephone
Text

(prefer mobile telephone)

Other:

If you have an answering machine or voice mail, may we leave messages regarding health management, treatment, and or other information pertinent to your healthcare and/or payment for your healthcare provided at Steven M. Pounders, M.D., P.L.L.C.? (Check one)

Multiple Choice *

Phone Number

If “NO”, how else may we contact you regarding this information?

Please list any other restrictions regarding messages or reminders about your healthcare:

Other Uses and Disclosures: Disclosure of your health information or its use of any purpose other than those listed in the “Consent to use and disclose protected health information” page of your new patient packet, requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision. You have the right to request restrictions on use and disclosure of your health information.

I would like the following restrictions regarding the use and disclosure of my health information:

STEVEN M. POUNDERS, MD, PLLC
Authorization of Use and Disclosure
of Protected Health Information

Persons Authorized to Receive Information:

Health Information Steven M. Pounders, M.D., P.L.L.C. collects or receives about you (such as appointment dates and times, diagnoses, lab tests, etc.) may be disclosed to the following persons:

Name of Person / Relation / Organization

Use and Disclosure of Information:

I authorize the person(s) listed above to receive ALL health information about appointments, treatment and/or other information pertinent to my healthcare and/or payment for my healthcare provided at STEVEN M. POUNDERS, M.D., P.L.L.C.

I authorize the person(s) listed above to receive only selected health information (i.e. appointment times, etc.), which Include:

which Include:

I do NOT authorize disclosure of my Health information to the following:

Expiration Date of Authorization:
This authorization is effecting through one year of the date signed unless revoked or terminated by the patient or patient’s personal representative.

Right to Terminate or Revoke Authorization:
You may revoke or terminate this authorization by submitting a written revocation to Steven M. Pounders, M.D., P.L.L.C. You should contact the PRIVACY OFFICIAL or other authorized representative to terminate this authorization.

Potential for Re-disclosure:
The person or organization to which health information is sent may repeatedly disclose health information that is identified by this authorization. The privacy of this information may not be protected under the federal privacy regulations.

Name of the Patient *

Name of Patient

Signature of Patient / Patient Representative *

Date *

Relationship of Patient Representative to Patient

Steven M Pounders, MD, PLLC
3500 Oak Lawn, Suite 600
Dallas, TX 75219-4373

INSURANCE BILLING, INSURANCE RIGHTS &
INSURANCE DISCLOSURE INFORMATION

I the patient, have made a contact through my employer with an insurance company to provide for third party reimbursement for medical care. As the patient, I am responsible for understanding, fulfilling, and having full knowledge of my insurance benefits, limitations, and restrictions.

I further understand and accept responsibility for complying with all such stated restrictions, limitations and provisions of my individual insurance policy. A failure on my part to comply with my obligations could result in a reduction or denial of my insurance benefits.

As a member of a PPO or a Managed Care Plan, I understand that my insurance company has set forth a system of guidelines to be utilized for reimbursement. By not meeting the guidelines deemed to be my responsibility I may severely limit or restrict my benefits. If I am seen today for a problem and do not have the appropriate referral number, all treatments for said problems could be severely limited or reduced. I accept the responsibility to make sure that I have met my criteria for my insurance company with my individual plan.

I further understand that I may have lab work/blood work that may be covered under my plan. However, this lab work/blood work may not be as inclusive as Steven M. Pounders, MD usually prefers. Blood tests such as HIV Viral Load and Essential Metabolic Analysis are two tests my insurance company may or may not cover under my plan.

It is my responsibility to understand my policy and if charges are not covered, I will be responsible for them.

I also understand that any additional costs involved in collecting an outstanding balance not covered by insurance will be the sole responsibility of the patient, including but not limited to:
$35 for NSF/returned check, $50-$75 no-show fee, necessary attorney or collection agency fees, and/or interest.

Patient Name *

Patient Signature *

Date *

Current Employer/Position:

Previous Employer/Position:

Marital Status:

Single
Married
Partnered
Divorced
Widowed
Separated

(Select One Option)

SELECT ANY DISEASES THAT YOUR BLOOD RELATIVES ARE KNOWN TO HAVE:

High Blood Pressure
Cancer
Heart Attack
Diabetes
Kidney Disease
Stroke
Lung Disease
Neurological Disease
Blood Disorder

Other

FAMILY HISTORY

Medical Problem

Mother

Current Age or Age at Death

Mother Current Age or Age at Death

Father

Father Current Age or Age at Death

Brother

Brother Current Age or Age at Death

Sister

Sister Current Age or Age at Death

Grandmother

(mother’s side)

Grandmother Current Age or Age at Death

(mother’s side)

Grandfather

(mother’s side)

Grandfather Current Age or Age at Death

(mother’s side)

Grandmother

(Father’s side)

Grandmother Current Age or Age at Death

(Father’s side)

Grandfather

(father’s side)

Grandfather Current Age or Age at Death

(father’s side)

Children

Children Current Age or Age at Death

ALLERGIES *

N/A
Having Allergies

Allergies 1

Allergies 3

Allergies 5

Allergies 7

Allergies 2

Allergies 4

Allergies 6

Allergies 8

CURRENT MEDICAL PROBLEMS or SYMPTOMS *

N/A
Having Problems

PROBLEMS or SYMPTOMS 1

PROBLEMS or SYMPTOMS 2

PROBLEMS or SYMPTOMS 3

PROBLEMS or SYMPTOMS 4

PROBLEMS or SYMPTOMS 5

PROBLEMS or SYMPTOMS 6

PROBLEMS or SYMPTOMS 7

PROBLEMS or SYMPTOMS 8

PAST MEDICAL PROBLEMS (please indicate dates) *

N/A
Having Problems

PAST MEDICAL PROBLEMS 1

PAST MEDICAL PROBLEMS 2

PAST MEDICAL PROBLEMS 3

PAST MEDICAL PROBLEMS 4

PAST MEDICAL PROBLEMS 5

PAST MEDICAL PROBLEMS 6

Single Line Text

INJURIES or ACCIDENTS (please indicate dates) *

N/A
Having Injuries or Accidents

INJURIES or ACCIDENTS 1

INJURIES or ACCIDENTS 2

INJURIES or ACCIDENTS 3

INJURIES or ACCIDENTS 4

INJURIES or ACCIDENTS 5

INJURIES or ACCIDENTS 6

INJURIES or ACCIDENTS 7

INJURIES or ACCIDENTS 8

OPERATIONS (please indicate dates) *

N/A
Having Operates

OPERATIONS 1

OPERATIONS 2

OPERATIONS 3

OPERATIONS 4

OPERATIONS 5

OPERATIONS 6

OPERATIONS 7

OPERATIONS 8

SMOKING HISTORY

NON Smoker
CURRENT Smoker
PREVIOUS Smoker
less than one pack a day
more than pack a day

ALCOHOL HISTORY

NON Drinker
SOCIAL Drinker
MODERATE Drinker
HEAVY Drinker

drinks per week

WEIGHT: (list usual weight in pounds)

HEIGHT: (feet & inches)

EXERCISE HISTORY: (select one option)

NONE
OCCASIONALLY
FREQUENT

DIETARY HISTORY: (select one option)

Regular Diet (no restrictions)
Low Salt
Low Cholesterol
Diabetic
Vegetarian
No Red Meat
Weight Reduction
Other

CURRENT MEDICATIONS (include over the counter medicines) *

N/A
Having Medication

CURRENT MEDICATIONS 1

CURRENT MEDICATIONS 2

CURRENT MEDICATIONS 3

CURRENT MEDICATIONS 4

CURRENT MEDICATIONS 5

CURRENT MEDICATIONS 6

CURRENT MEDICATIONS 7

CURRENT MEDICATIONS 8

CURRENT MEDICATIONS 9

CURRENT MEDICATIONS 10

CURRENT MEDICATIONS 11

CURRENT MEDICATIONS 12

**Name of Current Pharmacy or Pharmacy most convenient to you:

Pharmacy Name:

Phone

Address

Address Line 1

GYNECOLOGICAL HISTORY (women only)

Date of last menstrual period

Number of Deliveries

Last mammogram

Number of Pregnancies

Last PAP smear

Do you examine your breast regularly?

HAVE YOU RECENTLY EXPERIENCED ANY OF THE FOLLOWING?

(select all that apply)

Checkboxes

Weight Loss
Weight Gain
Loss of Appetite
Fever
Night Sweats
Headaches
Visual problems
Hearing Loss
Ringing in Ears
Nosebleeds
Hoarseness
Difficulty Chewing
Difficulty Swallowing
Thyroid problems
Pneumonia
Asthma
Bronchitis
Coughing up Blood
Shortness of Breath
Palpitations
Change of Bowel Habits
Blood in Stool
Abdominal Pain
Nausea or Vomiting
Skin Rash
Frequent Urination
Burning During Urination
Blood in Urine
Kidney Stones
Impotence
Hot Flashes
Hernias
Hemorrhoids
Muscle Aches
Joint Pains
Excessive Fatigue
Intolerance to Cold
Intolerance to Heat
Swelling of the Feet
Fainting
Loss of Balance
Difficulty with Speech
Paralysis
Weakness
Insomnia
Lack of Sexual Drive
Vaginal Discharge
Irregular Periods
Painful Menstrual Periods

VACCINATION/IMMUNIZATION HISTORY:

Date of last Tetanus Shot:

Have you had any of the following?

Influenza (flu shot)

Date

Multiple Choice

Twin Rx

Date

Multiple Choice

Hepatitis A

Date

Multiple Choice

Hepatitis B

Date

Multiple Choice

Pneumovax

Date

Multiple Choice

MMR

(measles, mumps, rubella)

Date

Multiple Choice

TB/PPD Skin Testing

Date

Multiple Choice

Pneumococcal Vaccine

Date

Multiple Choice

Haemophilus Influenza Vaccine

Date

Multiple Choice

Please list additional Vaccinations/Immunizations *

N/A
Having Additional Vaccinations/Immunizations

Single Line Text

Steven M Pounders, MD, PLLC
3500 Oak Lawn, Suite 600
Dallas, TX 75219-4373
214-520-8833 Fax 214-520-2956

REQUEST FOR RELEASE OF MEDICAL RECORDS

PATIENT RECORDS AND INFORMATION PERTAINING TO:

Patient Name:

Address

Line 1

City

State

Zip

Social Security Number:

Phone Number

Date of Birth

MM/DD/YYYY

I AUTHORIZE:

Name of Disclosing Doctor/Party:

Address

Line 1

City

State

Zip

Phone Number

Fax Number

to dispose to:

Steven M Pounders, MD, PLLC
3500 Oak Lawn, Suite 600
Dallas, TX 75219-4373
214-520-8833 FAX 214-520-2956

I requesting and authorizing that any and all medical information pertaining to my diagnosis and treatment be released to Steven M. Pounders, MD, PLLC to include Laboratory, EKG, Stress Tests, Echoes, Nuclear Studies, Hospital Admission and Discharge Summaries, Medical Treatment and Treatment Progress, or information (including information regulated by 42 USC Section 290dd3 (alcohol) and 290ee3 (drug abuse) and mental information regulated by TEX,CIV,STAT.ANN, Article 5561H, 5547-87, Texas Rule of Evidence, Rule 510, and Article 4419(b)-1, VTCS (HIV). The releases of my records are so that I may continue to receive medical care. I understand that my medical records (including alcohol, drug abuse, and mental status information and HIV test results) are protected by Federal Regulation and/or State Law. I also understand that I may revoke this consent at any time, except for action which was taken based on it, by sending written notification to the practice’s Privacy Contact at 3500 Oak Lawn, Suite 600, Dallas TX 75219. The office of Steven Pounders, MD, PLLC will condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested use of disclosure except (1) if my treatment is related to research, or (2) health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party. This consent will expire in 90 days.

Signature of Patient, Parent, Guardian, or Legal Representative *

Date *

MM/DD/YYYY

This information is confidential pursuant to Federal and State Law and is protected from further disclosure without the specific written consent of the above individual(s).

Message

New Patient Packet

Steven M Pounders, MD, PLLC 3500 Oak Lawn, Suite 600 Dallas, TX 75219-4373

PATIENT INFORMATION UPDATE

DEMOGRAPHICS

INSURANCE

Are you the PRIMARY policy holder?

POLICY HOLDER INFORMATION

EMERGENCY CONTACT INFORMATION

STEVEN M. POUNDERS, MD, PLLC CONSENT TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

THE NOTICE OF PRIVACY PRACTICES

YOU MAY PLACE RESTRICTIONS ON THE USE OR DISCLOSURE OF YOUR HEALTH INFORMATION

YOU MAY REVOKE THIS CONSENT AT ANY TIME

CHANGES TO PRIVACY PRACTICES

SIGNATURE

STEVEN M. POUNDERS, MD, PLLC Authorization of Use and Disclosure of Protected Health Information

STEVEN M. POUNDERS, MD, PLLC Authorization of Use and Disclosure of Protected Health Information

Persons Authorized to Receive Information:

Steven M Pounders, MD, PLLC 3500 Oak Lawn, Suite 600 Dallas, TX 75219-4373

FAMILY HISTORY

Medical Problem

Current Age or Age at Death

**Name of Current Pharmacy or Pharmacy most convenient to you:

GYNECOLOGICAL HISTORY (women only)

HAVE YOU RECENTLY EXPERIENCED ANY OF THE FOLLOWING?

VACCINATION/IMMUNIZATION HISTORY:

Have you had any of the following?

Influenza (flu shot)

Twin Rx

Hepatitis A

Hepatitis B

Pneumovax

MMR

TB/PPD Skin Testing

Pneumococcal Vaccine

Haemophilus Influenza Vaccine

Steven M Pounders, MD, PLLC 3500 Oak Lawn, Suite 600 Dallas, TX 75219-4373 214-520-8833 Fax 214-520-2956

REQUEST FOR RELEASE OF MEDICAL RECORDS

PATIENT RECORDS AND INFORMATION PERTAINING TO:

I AUTHORIZE:

to dispose to:

Steven M Pounders, MD, PLLC 3500 Oak Lawn, Suite 600 Dallas, TX 75219-4373 214-520-8833 FAX 214-520-2956

This information is confidential pursuant to Federal and State Law and is protected from further disclosure without the specific written consent of the above individual(s).

Steven M Pounders, MD, PLLC
3500 Oak Lawn, Suite 600
Dallas, TX 75219-4373

STEVEN M. POUNDERS, MD, PLLC
CONSENT TO USE AND DISCLOSE
PROTECTED HEALTH INFORMATION

STEVEN M. POUNDERS, MD, PLLC
Authorization of Use and Disclosure
of Protected Health Information

STEVEN M. POUNDERS, MD, PLLC
Authorization of Use and Disclosure
of Protected Health Information

Steven M Pounders, MD, PLLC
3500 Oak Lawn, Suite 600
Dallas, TX 75219-4373

Steven M Pounders, MD, PLLC
3500 Oak Lawn, Suite 600
Dallas, TX 75219-4373
214-520-8833 Fax 214-520-2956

Steven M Pounders, MD, PLLC
3500 Oak Lawn, Suite 600
Dallas, TX 75219-4373
214-520-8833 FAX 214-520-2956