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Welcome to Internal Medicine of Northern Virginia and thank you for selecting our practice for your medical care
-Please arrive 10-15 minutes in advance of your appointment. If you are late for your appointment, the physician may not be able to address all of your medical issues during your initial visit. If too late, your appointment might need to be rescheduled. We make every effort to see patients in a timely fashion and your prompt arrival and completion of the appropriate information below, helps us accomplish that.
-We presently do not participate with any insurance products. As such we request full payment of all charges at the time of your appointment. Please bring all necessary insurance information and cards with you because of potential need for preauthorization.
-We accept MasterCard, VISA, a local personal check with ID and cash
-Please bring your medication bottles with you to your first appointment. This would include both prescription and over the counter supplements.
-If you are unable to keep your appointment, we expect to be notified of your cancellation at least 24 hours PRIOR to your appointment. Many patients are interested in establishing themselves with our office and thus we have a substantial waiting list. If insufficient or no notice is given, we reserve the right to generate a cancellation fee of up to $150.
Please select the documents below that most appropriately match your needs. In particular:
- All new patients please complete documents #1 - 4
- If your concerns include fatigue, fibromyalgia or Lyme disease please also complete documents #5-8
- If fibromyalgia is of concern, please complete document #9
- If interested in our following you for primary care issues: #10
Thank you for your patience in completing this extensive documentation. Because of the complexities of many of your problems, we make every attempt to be as thorough as possible.
New Patient Information [to be completed ONLY at the time of the INITIAL VISIT ONLY] Thank you:
1. HIPAA
2. History of Present Illness-why are you being seen
3. Past Medical History
4. Review of Symptoms
5. Lyme specific questionnaire
6. Symptom questionnaire
7. The following section refers to medication or supplements previously used. Please leave BLANK if a particular category is not appropriate, ie a particular medicine or supplement has not been used: Medication Response History Part 1
Medication Response History Part 2
Medication Response History Part 3
8. Questionnaires for new patients with concerns of fatigue, Lyme or fibromyalgia
Please note that this option is not interactive, but rather requires printing of documents to
be completed and brought in with you to your office visit.
9. Questionnaire for just patients with the concern of fibromyalgia
10. For patients interested in primary care management: Immunization and preventive care history
Please fax to 703 709-7496 [or attach as a response to this email] any historical records including lab results, procedures, etc, that would be of value at your first visit.
Please note: for FASTING appointments: no eating anything for 8 hours, but you can take medication with water or black coffee. If because you anticipate having your labs obtained off site as a result of insurance participation issues, you will not need to fast, even if our staff may have inadvertently communicated that to you.
mail order pharmacy-most insurance companies prefer that ongoing medication be processed through their "mail order" contracted pharmacies. As such it is generally only through this mechanism that 90 days supplies can be filled. Locally pharmacies generally are only allowed to provide 30 day supplies. Please forward to us your pharmacy ID# and fax number to the mail order program with which your insurance is associated. We can then directly fax 90 day supplies of your medications.
Please make sure to complete this documentation and click SEND in order to complete this process. You SHOULD receive a verification notification that that section has been received.
We look forward to your first visit with us and appreciate any comments or suggestions that you might have.
Thank you in advance for your assistance.
Samuel Shor, MD, FACP, Eboni Smith, MD, Art Hammarstrom, FNP and Irina Nikitina, ANP
In order to reply to a message sent from our office, you must first sign in to our web site portal. This will allow for a secure communication. Please do not simply hit "reply" unless you have already signed into our web site.
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