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AMA

New Patient Packet

Gender

Male

Female

Other

Take A Picture Of The Front Of Your Driver License

Marital Status

Single

Married

Divorced

Widowed

Separated

With Partner

May we take your Picture for your Electronic Medical Record?

Yes

No

Take A Picture Of You

Ethnicity

White

Asian

Native Hawaiian/ Pacific Islander

Black/African American

American Indian/Alaskan Native

Hispanic/Latino

Prefer not to answer

Other

Other answer:

Emergency Contact

Please provide the name and phone number of a person we can contact in case of an emergency.

How did you hear about us?

Google

Facebook

Instagram

Friend

TikTok

Online Ad

Yelp

Email

Other

Other answer:

How do you wish to pay for your care?

Out of Pocket

Insurance

Pharmacy Information

Please provide all pharmacy information

Retail Pharmacy Cross Streets

Mail Order Pharmacy Information

Please provide all mail order pharmacy information

Patient Medical Review

Please provide all patient medical information

Allergic to Latex?

Yes

No

Allergic to shellfish?

Yes

No

Allergic to iodine?

Yes

No

Do you have any medication or drug allergies?

Yes

No

For female patients only

Was the pap smear normal?

Normal

Abnormal

Was the mammogram normal?

Normal

Abnormal

For male Patient's only

Was the PSA normal?

Normal

Abnormal

Do you have a history or currently have any major illnesses?

Yes

No

Do you have a history of any major surgeries or hospitalizations?

Yes

No

Select what screenings you have had.

Have you had a Bone Density screening?

Yes

No

Have you had a colonoscopy screening?

Yes

No

Medical History

Check if you have had the following (check ALL that apply):

Alcoholism/Addiction

Anemia

Anxiety/Depression

Arthritis

Asthma

Auto-Immune Disorder(s)

Bleeding Disorder

COPD

Cancer

Cataracts

Chicken Pox

Clotting Disorder

Colitis

Congestive Heart Failure

Connective Tissue Disorder

Crohn's Disease

Diabetes: Type I or II

Dialysis

Diverticulitis

Drug Dependency

Eczema

Emphysema

Epilepsy

Fibromyalgia

Gall Bladder Disease

Gallstones

Gastroparesis

Glaucoma

Gout

HIV/AIDS

Heart Disease

Heart Murmur

Heart Valve

Hemochromatosis

Hepatitis A, B or C

Hiatal Hernia

High Cholesterol

Hormone Replacement

Hypertension

Hysterectomy

Joint Replacement

Kidney Disease

Kidney Stones

Leg Cramps

Liver Disease

Lupus

Lyme's Disease

MTHFR

Measles

Meningitis

Migraines/Headaches

Multiple Sclerosis

Mumps

Osteoporosis

PCOS

POLIO

POTS

Pacemaker

Pelvic Infection

Pneumonia

Prostate Condition

Psoriasis

Rheumatic Fever

Rheumatoid Arthritis

STD/STI

Scarlet Fever

Scleroderma

Shingles

Stent Placement

Stomach Ulcers

Stroke

Thyroid Disorder

Tuberculosis

Vitiligo

Have you ever smoked?

Yes

No

Any other tobacco, vap or e-cig products?

Yes

No

Have you ever used recreational drugs?

Yes

No

Do you drink alcohol

Yes

No

Do you drink caffinated beverages | coffee?

Yes

No

Do you use illegal street drugs?

Yes

No

Mental Health Questions

Check if you have had the following (check ALL that apply):

Do you feel depressed?

Yes

No

Family Medical History

Select one or more family members if they had any of the medical conditions below.

Alcoholism/Addiction

Mother

Father

Maternal Grandmother

Maternal Father

Paternal Mother

Paternal Father

Bleeding Disorder

Mother

Father

Maternal Grandmother

Maternal Father

Paternal Mother

Paternal Father

Cancer

Mother

Father

Maternal Grandmother

Maternal Father

Paternal Mother

Paternal Father

Diabetes

Mother

Father

Maternal Grandmother

Maternal Father

Paternal Mother

Paternal Father

Heart Attack

Mother

Father

Maternal Grandmother

Maternal Father

Paternal Mother

Paternal Father

High Blood Pressure

Mother

Father

Maternal Grandmother

Maternal Father

Paternal Mother

Paternal Father

High Cholesterol

Mother

Father

Maternal Grandmother

Maternal Father

Paternal Mother

Paternal Father

Kidney Disease

Mother

Father

Maternal Grandmother

Maternal Father

Paternal Mother

Paternal Father

Mental Health Disorders

Mother

Father

Maternal Grandmother

Maternal Father

Paternal Mother

Paternal Father

Stroke

Mother

Father

Maternal Grandmother

Maternal Father

Paternal Mother

Paternal Father

Tuberculosis

Mother

Father

Maternal Grandmother

Maternal Father

Paternal Mother

Paternal Father

Is your mother still alive?

Yes

No

Is your father still alive?

Yes

No

Medications

Are you currently taking any medications?

Yes

No

I agree that my typed signature represents my legal signature and is valid for all purposes.

Advanced Directives (Living Will)

If you Have advanced directive (living will) please fill out the following.

Do you have a Health Care Power of Attorney?

Yes

No

living will

Yes

No

Pre-Hospital Medical Directives

Yes

No

I agree that my typed signature represents my legal signature and is valid for all purposes.

Notice of Privacy Practices

If You Need a copy of this form, please ask the office staff.

Notice of Privacy Practices

The Notice of Privacy Practices describes how this practice may use and disclose your medical information, as well as your rights to access your medical information. The HIPAA Privacy Rule permits this practice to disclose your protected health information to carry out Treatment, Payment, or other Healthcare Operations. We may also disclose your health information for purposes required by law. HIPAA also grants you the right to access and control your protected health information. We must abide by the information outlined in the Notice of Privacy Practices. As HIPAA evolves, we reserve the right to update our Notice of Privacy Practices at any time.HIPAA Permits and requires additional uses and disclosure that may be made without your authorization or opportunity to agree or object. These situations include:

Disclosures Required By Law and Workers Compensation:

We are permitted to use or disclose your protected health information to the extent that the law requires the use or disclosure. We will maintain compliance with the law and will limit the disclosure to the minimum necessary. If required, you will be notified of any disclosure. We are permitted to disclose your protected health information as authorized to comply with workers' compensation laws and other similar established programs. Your protected health information may be used and disclosed by your physician, our office staff, and others who are involved in your treatment, payment, or other healthcare operations. The following are common examples that our practice is

Abuse or Neglect:

We believe abuse or Reflect to be a serious issue. We may disclose your protected health information to a public health authority authorized to receive reports of child abuse or neglect. Way also discloses your information if, in our best judgment, we believe you have been a victim of abuse, neglect, or domestic violence. When disclosing protected healthier formation in cases of abuse or neglect, we will follow applicable state and federal laws.

Treatment:

Our practice will use and disclose your protected health information to provide, coordinate, or manage your health care. This includes the coordination or management of your healthcare with another provider. We will disclose protected health information to any other physicians who may be treating you. We may also disclose your protected health information to another physician or healthcare provider such as a laboratory, which becomes involved in your treatment.

Payment:

Our practice will use and disclose health information, to obtain] payment for your services performed by the US or by another provider. This may include disclosures to health insurance plans, insurance providers, and collection agencies.

Business Associates:

We will share your protested health information with a third, party business associates that perform various activitiés Examples of business associates include, billing services, transcription services, and legal services. Before disclosing any protected health information with a búshness associate, we will establish a written contract that contains the térms that will protect the privacy of your information. Business Associates and their subcontractors must also comply with HIPAA Privacy and Security Regulations Health Care Operations: Our practice will use and disclose your protected health information to support our practice's business activities. Examples include, but are not limited to, quality assessment, employee reviews, medical student training, licensing, fundraising, and conducting or arranging for other business activities.

Public Health and Communicable Diseases:

We are permitted to disclose your protected health information for public health purposes or to a public health authority that is permitted by law to collect or receive the information. Examples may include disclosure to prevent or control disease, or injury. We are permitted to disclose your protected health information, if authorized by law, to a person who may have unexposed to a communicable disease. We may disclose your information if said person may be at risk of contracting or spreading the disease or condition. Research and Health Oversight: We are permitted to disclose your protected health information to researchers when an institutional review board that has reviewed the research proposal, as well as established protocols to ensure the privacy of your information has approved their research. We are permitted to disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.

Legal Proceedings:

We are permitted to disclose protected health information in connection with any judicial or administrative proceeding, subpoena, or in responding to court order or tribunal.

Law Enforcement:

We may also disclose protected health information, under lawful conditions to law enforcement. Permitted law enforcement purposes include; 1 Legal processes and otherwise required by law, 2 Limited information requests for identification and location purposes, 3 About the victim of a crime; 4 Suspicion that death has occurred as a result of criminal conduct; 5 If a crime occurs on the premises of our practice, and 6 Medical emergencies associated with a crime.

Organ Donation, Coroners, & Funeral Directors: We are permitted to disclose protected health information to a coroner or medical examiner to perform other duties. Disclose may be made in reasonable anticipation of death. Protected health may be used and disclosed for cadaveric organ, eye, or tissue donation purposes. Military Activity & National Security: We are permitted to use or disclose protected health information of individuals who are Armed Forces personnel under the following circumstances; 1 For activities deemed necessary by appropriate military command authorities; 2 For a determination by the Department of Veteran Affairs of your eligibility for benefits, or 3 To foreign military authority if you are a member of that foreign military services. We are also permitted to disclose your information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protected services to the President or others legally authorized. Written Authorization: Unless required by law, your written authorization will be required for all other uses and disclosures of your protected health information. You may revoke the authorization at any time, by written request. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Note: We are unable to undo any disclosures previously made with your authorization. Opportunity to agree or object: The following are examples of instances where we may use and disclose your protected health information; however, you have the opportunity to agree or object) to the use or disclose of all or part of the disclosure. If you arégot present or can agree or object to the use or disclosure, then we may use professional judgment, to determine whether the disclosure is In your best interest. Unless you object, we may disclose to a member o your family, a relative, or à close friend, your protected health information that directly relates to that person's involvement in your We may use or disclose protected health information to notify or assist in notifying family members personal représentative or any other pérson that is responsible for the care of your location, genéral condition or death. Finally, we may use or discloséyour information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your care. Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition, and your religious affiliation. This information, except religious affiliation, will be disclosed to individuals who ask for you by name You're religion will only be given to a member of the clergy, such as a priest or rabbi. You have the right to inspect and copy your protected health information. As long as we are maintaining your protected health information, you may inspect and obtain a copy of your protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physicians use for health care decisions. As permitted by federal or state law, we may charge you a "reasonable copy fee" for a copy of your records. However, federal law prohibits you from inspecting or copying: Psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access. You have the right to appeal the denial. Please contact our Practice Manager if you have any Lesions. You have the right to request a restriction of your protected health information. You may ask the US not to use or disclose any part of your protécted health Information 1 For treatment, health care operations, or payment; 2 to family members or friends who may be involved in your care or 3 For notification purposes as described in this Notice of Privacy Practices. Your written request must state the specific restriction requested and to whom you want the restriction to apply. We are NOT required to agree to restrictions that you request unless your account has been paid in full. However, if your physician does not agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction other than emergency treatment situations. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We strive to accommodate all reasonable requests. As a condition, we may ask for additional information, such as payment, alternative address, or additional contact information. We will not request an explanation for the request. Notify our Practice Manager in writing for all requests. You have the right to receive an accounting of certain disclosures made. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized the US to make the disclosure, for a facility directory, to a family member(s) or friend (s) involved in your care. Or for notification purposes, national security or intelligence, law enforcement or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions, and limitations. You may request an amendment of your protected health information in a designated record set for so long as we maintain this information. We may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement and we may provide you with a copy of any rebuttal. Please contact our Practice Manager if you have questions

1915 E Chandler Blvd. Ste. 1, Chandler, AZ 85225 20928 N John Wayne Pkwy Ste. C-4, Maricopa, AZ 85139 www.AmericanMedicalAssociatesAZ.com

HIPPA Authorization for Release of Medical Information

If You Need a copy of this form, please ask the office staff.

The Health Insurance Portability and Accountability Act (HIPAA) provide safeguards to protect your privacy. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, and/ or health insurance payers as is necessary and appropriate for your care. The patient hereby waives his/her confidentiality right should collection action become necessary. You have the right to request restrictions in the use of your protected health information and to request changes in certain policies used within this office. However, we are not obliged to alter internal policies to conform to your request.

My protected health information may be released to the following people:

Person One

Person Two

Person Three

Person Four

Acknowledgement of Receipt of Notice of Privacy Practices

HIPAA - Notice of Privacy Practices:

I agree that my typed signature represents my legal signature and is valid for all purposes.

FINANCIAL POLICY /CANCELLATION POLICY AGREEMENT

If You Need a copy of this form, please ask the office staff.

FINANCIAL POLICY

All insurance providers have different coverage and benefit levels depending on what you have chosen to purchase or what your employer has chosen. It is your responsibility to be aware of your benefits. We strongly encourage you to be in contact with your insurance agent to determine the level of coverage your plan provides, as well as have an understanding of the financial figures you will be responsible for. We participate with most insurance plans. If you are an HMO patient, you must choose Dr. Ehreema Nadir, MD as your primary care physician. This can be done by calling your insurance company before your appointment and having them list our physician as the PCP. You will be responsible for the visit if Dr. Ehreema Nadir, MD is not listed as the PCP, or you will have to reschedule to a later date when the physician is effective. As a courtesy, we will submit your claim for all services to your insurance company. Please remember your health insurance policy is a contract between you and your insurance company and we are not a party to that contract. Be aware that some services may not be covered by your insurance policy. By presenting for care, you agree that you are responsible for all services and charges regardless of your insurance status. Should any provided services not be covered by your insurance, we will not alter your claim, change your diagnosis, or report a different service than what was performed so that your insurance will cover the charge. This constitutes fraud and will not be done and you will be responsible for the balance. All co-pays, balances, and deductibles are due at the time of service. We file your insurance and then any balances that are due by you must be paid within 90 days unless prior arrangements have been made with the billing department. If you have a billing or insurance-related question, please contact our billing office at (480) 306-5151 and they will be happy to assist you. We ask patients to refrain from discussing billing questions with the physicians, nurse practitioners, or physician's assistants as they devote their time and expertise to your health care and cannot answer billing questions. Any account left unpaid after 90 days will be turned over to an outside collection agency. Any collection fees necessary for this debt will be added to the outstanding balance. Please keep in mind that should your account go into collections, any arrangements/payments will need to be made directly with the collection agency. In addition, once an account has been turned over to the collection agency, the patient may receive a letter of discharge from our practice.

Cancellation Policy

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. You MUST give our office 24 hours' notice before your scheduled appointment. Multiple "No-Shows" in any 12 months may result in termination from our practice. "No-Show" fees will be billed to the patient. This fee is NOT covered by any insurance plan and will be your responsibility. Our practice fees are listed below. $50.00 - Request to complete Disability, FMLA, Life, and various other types of independent health forms. Forms MUST be present at the time of visit, or you will be asked to be rescheduled. $25.00 - Returned checks for non-sufficient funds will have a processing fee that will be charged back to the patient. We will be unable to accept any personal checks after the first occurrence. $50.00 - Charge for missed appointments or appointments canceled with less than 24-hour notice with the Physician, Nurse Practitioner, or Physicians' Assistant. $75.00 - Charge for missed appointments or appointments canceled with less than 24-hour notice with the Psychiatric Nurse Practitioner and Nephrologist. By signing below, I acknowledge that I have read and understood the financial and cancellation policies of American Medical Associates and agree to the policies set forth.

I agree that my typed signature represents my legal signature and is valid for all purposes.