Patient History Form for review

Patient Information

DIALYSIS (If Applicable):

VAWNY is required by federal regulations to aid health agencies in understanding healthcare disparities, improving quality of care, and strengthening research and outreach. We appreciate your assistance in meeting these standards by answering the following questions. VAWNY is dedicated as your partner in improving patient care.

Please have your insurance cards and picture ID available for photocopying at each visit. All Copays and balances are due at the time of the service unless prior arrangements have been made.

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I also understand and agree that any balance due and not received within 60 days of becoming patient responsibility shall be considered past due and my account shall be in default. It may become necessary to engage a firm to collect any past-due balance.

In a case where I am unable to make my appointment, I understand that I must give at least 24 hours' notice to the office or answering service by phone, or I will be assessed a missed appointment fee. This fee is not covered by insurance and will be due and must be paid prior to making any further appointments.

I have received a copy of the Vascular Associates of WNY HIPAA Notice of Privacy Practices

Please select YES or NOto the following questions:

I give the Physicians and staff of VAWNY permission to discuss health information, in person, by telephone or video, with the following family members or friends involved in my care:

• This document does not allow for the release of any written health information to the individuals named above.
• Reports needed by other health care facilities or insurance companies for my care may be released at the doctor’s discretion.
• If at any time you would like any of the above names removed, please send written notice to our office or come and fill out another form.
• I authorize the release of medical information necessary in the coordination of my medical treatment/care.