This document contains patient registration and insurance information forms for Potomac Urology Center. It requests the patient's personal details, insurance coverage, primary care physician information, and provides spaces for the patient's signature to authorize assignment of benefits and consent to treatment. The forms also collect medical history, social history, billing policies, and privacy notice acknowledgements from the patient.
This report is a practical guide to understand the cultural factors that reinforce social tensions in Mozambique, bring to light the dominant social tensions that currently exist, and present general recommendations for mitigating risks. Incorporating a community-based approach into existing security and corporate social responsibility activities creates more effective engagement strategies that are legitimate in the eyes of the Mozambican population, and fundamentally support the needs of Mozambique’s communities where our clients operate.
DOC ini dibuat oleh Riksa Rizki Zetta Adeli dan tim.
Di dalamnya, terdapat hasil dan pembahasan survey perkembangan smartphone di Jember. Semoga dapat bermanfaat.
http://facebook.com/rrza28
http://twiter.com/risarizi
http://noonecanfly.blogspot.com
According to The USDA system of Soil Taxonomy Twelve soil soil orders are recognized. Andisols is one of them.
Globally, Andisols are the least extensive soil order and only account for >1% of the ice-free land area.
Últimos datos oficiales sobre IPC registrados por el INE, Marzo 2014.
Conoce cómo han cambiado los precios de nuestros bienes de consumo: transporte, vivienda, enseñanza, etc..
Par Q Form pdf. you can download for your personal trainer business. These forms are also known as Physical Activity Readiness Questionnaires.
Par Q's help you determine if your client is ready for a physical fitness program. It's important to ask your clients to fill out at least one par q form before starting any program.
This report is a practical guide to understand the cultural factors that reinforce social tensions in Mozambique, bring to light the dominant social tensions that currently exist, and present general recommendations for mitigating risks. Incorporating a community-based approach into existing security and corporate social responsibility activities creates more effective engagement strategies that are legitimate in the eyes of the Mozambican population, and fundamentally support the needs of Mozambique’s communities where our clients operate.
DOC ini dibuat oleh Riksa Rizki Zetta Adeli dan tim.
Di dalamnya, terdapat hasil dan pembahasan survey perkembangan smartphone di Jember. Semoga dapat bermanfaat.
http://facebook.com/rrza28
http://twiter.com/risarizi
http://noonecanfly.blogspot.com
According to The USDA system of Soil Taxonomy Twelve soil soil orders are recognized. Andisols is one of them.
Globally, Andisols are the least extensive soil order and only account for >1% of the ice-free land area.
Últimos datos oficiales sobre IPC registrados por el INE, Marzo 2014.
Conoce cómo han cambiado los precios de nuestros bienes de consumo: transporte, vivienda, enseñanza, etc..
Par Q Form pdf. you can download for your personal trainer business. These forms are also known as Physical Activity Readiness Questionnaires.
Par Q's help you determine if your client is ready for a physical fitness program. It's important to ask your clients to fill out at least one par q form before starting any program.
A breif and a summary about how to take a well and nice history from patients condition.
In this 4 pages it covers all the necessarily quetions that you will ask your patient. I hope it's interesting.
Senior Life magazine, which I created and edited myself. Forgive the awkward layouts - the ads were sold in "pre-fab" blocks. I built the ads per client requests.
Screening Colonoscopy - What you need to know Michael Rausher
Atlanta Center for Gastroenterology, P.C. located at 2665 North Decatur Rd. STTE #550 Decatur, GA 30033. Accepting new patients. Please call 404-296-1986
Potomac Urology is dedicated to providing personalized, state-of-the-art urology treatments with exceptional care and compassion. At Potomac Urology, we strive to bring you the best urological care along with the convenience and comfort of staying close to home.
Potomac Urology is dedicated to providing personalized, state-of-the-art urology treatments with exceptional care and compassion. At Potomac Urology, we strive to bring you the best urological care along with the convenience and comfort of staying close to home.
Potomac Urology is dedicated to providing personalized, state-of-the-art urology treatments with exceptional care and compassion. At Potomac Urology, we strive to bring you the best urological care along with the convenience and comfort of staying close to home.
Potomac Urology is highly dedicated to provide personalized and quality care by using minimal invasive techniques. All our doctors are certified by American Board of Urology and hold unique fellowship certifications as well. We provide efficient urological services throughout Northern Virginia. We provide state-of-art medical treatment for conditions including Impotence and incontinence, Female Urology, Vasectomy, Kidney Stones, Male Fertility, Erectile Dysfunction, Prostate Cancer, Kidney Cancer, Bladder Cancer and Testicular Cancer. We use latest diagnostic and therapeutic equipments and contemporary techniques including, Robotic Surgery, Laser Lithotripsy, Latest Digital Scope and Robotic Radical Cystectomy.
Potomac Urology is highly dedicated to provide personalized and quality care by using minimal invasive techniques. All our doctors are certified by American Board of Urology and hold unique fellowship certifications as well. We provide efficient urological services throughout Northern Virginia. We provide state-of-art medical treatment for conditions including Impotence and incontinence, Female Urology, Vasectomy, Kidney Stones, Male Fertility, Erectile Dysfunction, Prostate Cancer, Kidney Cancer, Bladder Cancer and Testicular Cancer. We use latest diagnostic and therapeutic equipments and contemporary techniques including, Robotic Surgery, Laser Lithotripsy, Latest Digital Scope and Robotic Radical Cystectomy.
Potomac Urology is dedicated to providing personalized, state-of-the-art urology treatments with exceptional care and compassion. At Potomac Urology, we strive to bring you the best urological care along with the convenience and comfort of staying close to home.
Potomac urology center patient registration formpotomacurology
Potomac Urology is dedicated to providing personalized, state-of-the-art urology treatments with exceptional care and compassion. At Potomac Urology, we strive to bring you the best urological care along with the convenience and comfort of staying close to home.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
For those battling kidney disease and exploring treatment options, understanding when to consider a kidney transplant is crucial. This guide aims to provide valuable insights into the circumstances under which a kidney transplant at the renowned Hiranandani Hospital may be the most appropriate course of action. By addressing the key indicators and factors involved, we hope to empower patients and their families to make informed decisions about their kidney care journey.
COVID-19 PCR tests remain a critical component of safe and responsible travel in 2024. They ensure compliance with international travel regulations, help detect and control the spread of new variants, protect vulnerable populations, and provide peace of mind. As we continue to navigate the complexities of global travel during the pandemic, PCR testing stands as a key measure to keep everyone safe and healthy. Whether you are planning a business trip, a family vacation, or an international adventure, incorporating PCR testing into your travel plans is a prudent and necessary step. Visit us at https://www.globaltravelclinics.com/
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...
Female patient registration form
1. POTOMAC UROLOGY CENTER
2296 Opitz Blvd., Suite 350 50 S. Pickett Street, Suite 201
Woodbridge, VA 22191 Alexandria, VA 22304
Tel: 703-680-2111 Fax: 703-878-3939 www.potomacurology.com
Patient Registration
Name: SSN: _____________________Sex: M / F/ Transgender
Last First MI
Home Address:
Street Address Apt No. City State Zip Code
Date of Birth: ____________________ Home Phone: ____________________ Cell Phone:
Employer/School: Full-time / Part-time: _______________________________ Email Address: ___________________
Employer/School Address:
Street Address City State Zip Code
Work Number: ________________________ Marital Status:
Whom may we thank for referring you today?
Pharmacy Name & Location Pharmacy Phone Primary Care Physician PCP Phone
Emergency Contact
Name: Relationship:
Home Phone: ______________ Mobile Phone: ____________ Work Phone:
Insurance Information
______________________________ _________________________________
Primary Insurance Secondary Insurance
______________________________ _________________________________
ID Number ID Number
______________________________ _________________________________
Group Number Group Number
______________________________ _________________________________
Subscriber’s Name/Relation Subscriber’s Name/Relation
______________________________ _________________________________
Subscriber’s Social Security Number Subscriber’s Social Security Number
______________________________ _________________________________
Subscriber’s Date of Birth Subscriber’s Date of Birth
______________________________ _________________________________
Subscriber’s Employer Subscriber’s Employer
______________________________ _________________________________
Subscriber’s Address if different than yours Subscriber’s Address if different than yours
I, __________________________________ hereby assign, authorize and request the payment from my insurance
carrier be paid directly to Potomac Urology Center, PC.
I certify that the information reported is correct, current, valid and complete. I hereby authorize the release of any
information for this or any other related claim to my insurance carrier.
I also realize that insurance coverage does not guarantee payment for services performed and all charges are my
responsibility, with payment in full due within 90 days from the date of service. I will contact my insurance carrier in 2
months, if my claims are still unpaid. I also agree that if there are any balances due or my claim is disputed or denied by my
insurance, I will pay in full immediately upon notification from them.
I understand that the prices are subject to change.
In the event that my account is placed in the hands of a collection agency and/or an attorney, I agree to pay all costs related to
the collection, which could be up to 33 1/3% additional to the balance due.
I understand that I will be charged $50.00 for all returned checks.
Patient/Parent Signature Printed Name DOB Date
2. POTOMAC UROLOGY CENTER
2296 Opitz Blvd., Suite 350 50 S. Pickett Street, Suite 201
Woodbridge, VA 22191 Alexandria, VA 22304
Tel: 703-680-2111 Fax: 703-878-3939 www.potomacurology.com
Name: _______________________________________ Date of Birth:
Last First MI
RACE: CHECK ONE ETHNICITY: CHECK ONE
NATIVE HAWAIIAN OR OTHER PACIFIC HISPANIC OR LATINO
BLACK OR AFRICAN AMERICAN NOT HISPANIC OR LATINO
WHITE REFUSED TO REPORT
HISPANIC
OTHER RACE
OTHER PACIFIC ISLANDER
UNREPORTED/REFUSED TO REPORT
LANGUAGE: CHECK ONE
ENGLISH
SPANISH
RUSSIAN
INDIAN (INCLUDES HINDI & TAMIL)
OTHER
Health Questionnaire
Reason for Today’s Visit:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Current Medical Conditions:
Past Surgical History:
__________________________________________________________________________________________
__________________________________________________________________________________________
_
Are you currently taking medications? Yes No
Are you taking Aspirin, Coumadin, Blood Thinners? □ Yes □ No
Please list medications:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you have any allergies to medications?
__________________________________________________________________________________________
I hereby consent to treatment by Potomac Urology Center, PC. I hereby authorize Potomac Urology
Center, PC to obtain my prescription history and any additional information they may request in regards
to my Medication History
Signature of Patient (legally responsible party) Date
3. POTOMAC UROLOGY CENTER
2296 Opitz Blvd., Suite 350 50 S. Pickett Street, Suite 201
Woodbridge, VA 22191 Alexandria, VA 22304
Tel: 703-680-2111 Fax: 703-878-3939 www.potomacurology.com
PAST MEDICAL, FAMILY AND SOCIAL HISTORY
Are you or a blood relative having problems (now or in the past) with any of the following?
□ No □ Yes If yes, please check all boxes that apply.
FAMILY
YOU MEMBER
Anemia □ □
Arthritis □ □
Asthma □ □
Cancer □ □
Type of Cancer:
Depression □ □
Diabetes □ □
GERD/Acid Reflux □ □
Gout (high uric acid) □ □
Heart Disease □ □
High Blood Pressure □ □
High Cholesterol □ □
Kidney Stones □ □
Liver Disease □ □
Mitral Valve Prolapse □ □
Osteoporosis □ □
Rheumatic Fever □ □
Thyroid Problems □ □
Toxic Exposure □ □
Tuberculosis □ □
Other/Explain: □ □
Have you had surgery on any of the following? If yes, please check all boxes that apply.
INCLUDE SURGERY DATE
YES NO
Appendix □ □
Back □ □
Bladder □ □
Breast □ □
Colon □ □
Gallbladder □ □
Heart Bypass □ □
Heart Valve □ □
Hernia □ □
Incontinence □ □
Kidney □ □
Lung □ □
Thyroid □ □
Urethra □ □
Total Joint Replacement □ □
Right: □ Hip □ Knee □ Shoulder □
Left: □ Hip □ Knee □ Shoulder □
Patient/Parent Signature Printed Name DOB Date
4. POTOMAC UROLOGY CENTER
2296 Opitz Blvd., Suite 350 50 S. Pickett Street, Suite 201
Woodbridge, VA 22191 Alexandria, VA 22304
Tel: 703-680-2111 Fax: 703-878-3939 www.potomacurology.com
SURGERIES CONTINUED:
***WOMEN ONLY YES NO
Hysterectomy □ □
Pelvic Laparoscopy □ □
Could you be pregnant? □ □
Number of Pregnancies: Vaginal Cesarean
***MEN ONLY
Prostate □ □
Testicle □ □
Vasectomy □ □
Have you ever had MRSA? □ □
Positive Mantoux/PPD? □ □
BOTH MEN & WOMEN
Do you or did you smoke? □ Yes □ No
If yes, how many packs per day? _____ How many years? ______When did you quit? _______
Do you drink alcohol? □ Yes □ No If yes, how much? _______________
Are you on a special diet? □ Yes □ No If yes, explain? __________________
Are you Employed? □ Yes □ No □ Retired Occupation? _____________
Do you have children? □ Yes □ No Year(s) of Birth? __________
Do you have any problems NOW related to the following systems? Please circle Yes or No.
Constitutional Symptoms Cardiovascular Respiratory
Fever Yes No Chest Pain Yes No Wheezing Yes No
Chills Yes No Varicose veins Yes No Frequent cough Yes No
Headache Yes No High/Low blood Shortness of
Weight Gain/Loss Yes No pressure breathe Yes No
Other: ________________ Other: ________________ Other: ________________
Endocrine Ear/Nose/Throat/Mouth Gynecologic
Excessive thirst Yes No Ear Infection Yes No Heavy periods Yes No
Too hot/Cold Yes No Sore throat Yes No Irregular periods Yes No
Tired/Sluggish Yes No Sinus problems Yes No Menopause Yes No
Other: _______________ Other: ________________ If yes, when? ____________
Integumentary Sexual History Hormone therapy Yes No
Skin Rash Yes No Sexually active? Yes No Other: ________________
Boils Yes No Pain with
Persistent rash Yes No intercourse? Yes No Neurological
Other: ________________ Leaking urine Tremors Yes No
with intercourse? Yes No Dizzy Spells Yes No
Gastrointestinal Other: ________________ Numbness Yes No
Abdominal Pain Yes No Hematologic/Lymphatic Headaches Yes No
Nausea/Vomiting Yes No Swollen glands Yes No Other: ________________
Indigestion Yes No Blood clotting
Heartburn Yes No Problem? Yes No Eyes
Constipation Yes No Pulmonary Blurred Vision Yes No
IBS Yes No Embolism Yes No Boils Yes No
Diarrhea Yes No Anemia Yes No Persistent rash Yes No
Rectal Bleed Yes No HIV/AIDS Yes No Other: _______________
Other: ________________ Other: ________________
Patient/Parent Signature Printed Name DOB Date
5. POTOMAC UROLOGY CENTER
2296 Opitz Blvd., Suite 350 50 S. Pickett Street, Suite 201
Woodbridge, VA 22191 Alexandria, VA 22304
Tel: 703-680-2111 Fax: 703-878-3939 www.potomacurology.com
Billing Policies
ASSIGNMENT OF BENEFITS: I hereby assign to you Potomac Urology Center, PC, all medical benefits to
what I am entitled, including Medicare or any other insurance plan. I hereby authorize said assignee, Potomac
Urology Center, PC to release all information to secure payment, including appeals on my behalf to the Insurance
Commissioner. I also authorize my insurance company to release any/all information to Potomac Urology Center,
PC that may be necessary to secure payment. I also understand that I am financially responsible for all charges my
insurance company states are patient responsibility, including any deductibles and copayments and that payments
are due at the time services are rendered. If Potomac Urology Center, PC does not participate with my insurance
company, I understand that I am responsible for all charges not paid by my insurance. I also understand that if I
am signing on behalf of my minor dependent, that I am responsible for all charges rendered patient responsibility.
I understand that in the event my account becomes past due (over 90 days) and all attempts to arrange
payment have failed, my account will be turned over to a collection agency and/or attorney. I also
understand that I will be responsible for all collection agency fees (33 1/3%) of total past due amount and
all other costs expended to the collection said amount.
NO SHOW FEE: It is our policy to require appointment cancellations no later than 48 hours in advance in order
to avoid a no show charge. Effective January 2, 2011 failure to notify Potomac Urology Center, PC within this time
limit or failure to show up for scheduled appointment will result in a $50 Office Visit fee, $200 CMG Testing fee,
$100 Cystoscopy fee, $500 Hospital Surgery fee, $100 Surgical Procedure’s in Office fee & $250 Vasectomy fee to
your account. This charge cannot be billed to any insurance company, IT IS YOUR RESPONSIBILITY. You
will receive a bill for this and payment is expected prior to your next appointment.
HMO PATIENTS: Potomac Urology Center, PC is a specialty medical practice. IT IS YOUR
RESPONSIBILITY TO OBTAIN REQUIRED REFERRALS FROM YOUR PRIMARY CARE
PHYSICIAN PRIOR TO EACH VISIT. For return patients, if you are uncertain whether or not you have a
valid referral on file, please call the office 48 hours prior to your visit to clarify the issue.
Appointments will be rescheduled if required referrals are not presented prior to or on the scheduled appointment
day.
PRIVACY NOTICE: My signature below confirms that I was given the opportunity to read, understand and ask
questions about Potomac Urology Center, PC Notice of Privacy Practices exhibited in the waiting room (copy given
upon request). I hereby authorize Potomac Urology Center, PC to release any information pertaining to my health
care, test results, billing and/or accounting information to the following person(s) or agencies. I understand that I
have a right to inspect and receive a copy of the disclosed material at a cost of $10 administration fee, $0.50 per
page for the first 50 pages and $0.25 per page after 50 pages. These charges are in accordance with the VA
CODE A01-4V13. I also understand that Potomac Urology Center, PC charges $25 to complete any additional
forms.
□ Myself □ My Significant Other □ Leave information on my voice mail
□ Others (specify): _____________________________________________
_____________________________________________
_____________________________________________
I certify that I understand and agree with the above policies. I also certify that the information I have given is
correct to the best of my knowledge.
Patient/Parent Signature Printed Name DOB Date