Westoaks Orthopaedic Associates

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1 Westoaks Orthopaedic Associates Name: Address: Patient ID #: Sex: M [ ] F [ ] Date of Birth: Social Security #: City, State, Zip: [ ] Home [ ] Work [ ] Mobile [ ] Married [ ] Single Referring Physician: Primary Physician: Address/Tel. No. PATIENT EMPLOYMENT Employer: Address: City,State,Zip: [ ] Employed [ ] Retired Guarantor [ ] Same as Patient Name: Address: City, State Zip: Employer: Social Security #: PRIMARY INSURANCE Insured Party: [ ] Same as Patient [ ] Same as Guarantor [ ] Other Pt s relation to Insured: Insured Social Security #: Date of Birth: Insured: Company: SECONDARY INSURANCE [ ] Same as Patient [ ] Same as Guarantor Insured Party: _ Pt s Relation to insured: Insured Social Security#: Date of Birth: Insured ID: Company: : Group policy no:: REASON FOR MEDICARE AS 2nd INSURANCE 0 Working Age Beneficiary or spouse with Employer Group Health Plan 0 Disabled Beneficiary under age 65 with Group Health Plan 0 Auto insurance is primary Signature

2 ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY Thank you for choosing Westoaks Orthopaedic as your health care provider. We require every patient to read and sign the following agreement before provision of care. We are happy to answer questions about this policy. If you refuse to sign this agreement, services will not be provided. If you do not have health insurance or if Westoaks Orthopaedic is not contracted with your insurance plan, you will be required to pay all charges, in full, at the time of service. -.: Should you have health insurance, it is your responsibility to provide us with complete, accurate, and up-to-date information in order for us to successfully bill your insurance company. It is also your responsibility to obtain any authorization or pre-certification required for insurance coverage before services are rendered. It is your responsibility to understand your benefits. We encourage you to contact your health plan Member Services representative with questions about coverage, pre-authorization or precertification requirements and to ensure that such requirements were met, prior to receiving services from us. Ultimately, you are responsible for any charges incurred which were not authorized or certified by your health plan. You understand and agree that it is your responsibility to pay applicable deductible, copayments, co-insurance, and all outstanding balances at the time of service. Your health plan may state it considers a proposed treatment not medically necessary, investigational or not proven medically effective, even though Westoaks Orthopaedic believes this is the best treatment for you. Should your health plan deny payment for such services provided to you by Westoaks Orthopaedic, you will be responsible for all charges, and there will be no contractual adjustment. If, for any reason, your health insurance does not pay for services rendered, you understand that you are responsible for all charges and, by signing below, agree to pay the full amount due upon receipt of a statement issued by WestOaks Orthopaedic. If Westoaks Orthopaedic does not receive your payment within 60 days, a monthly finance charge of 1.5% per month will be applied. I understand that this the policy of Westoaks Orthopaedic which shall not change based on date of service, type of service, health plan or change of health plan coverage. I have read the policy and fully understand my responsibilities and obligations. Patient Name (Print) Responsible party (Print) Signed Date

3 AUTHORIZATION I hereby authorize medical benefits otherwise payable to me be made directly to Westoaks Orthopaedic. I understand that my medical records and information may be made available to all entities directly related to WestOaks. I also authorize my doctor to release information regarding my treatment to my insurance carrier. I authorize treatment of the above named patient or dependent and agree to be financially responsible for all charges relating to treatment. In the event of special arrangements, I agree to make payment according to written financial agreement with the office. It is agreed and understood that payment by the responsible party will not be delayed or withheld because of any insurance coverage or pendency of claims. The undersigned hereby agrees that in the event of default in payment of any amount due, if this account is placed in the hands of an agency or attorney for collection or legal action, to pay an additional charge equal to the cost of collection including agency.and attorney fees and court costs incurred and permitted by laws governing these transactions. I accept full responsibility for any charges incurred as a result of medical-legal testimony provided by doctors in this office, whether requested by my attorney or another party. The charges incurred will be billed at the rate in effect at the time when services were rendered. I understand that such charges will not be covered by insurance and that I am responsible for them personally. This authorization and agreement will remain in effect for present and future conditions until such time that I expressly rescind this agreement in writing. PRIVACY STATEMENT: I understand that Westoaks Orthopaedic is required by law to provide me with a copy of the Privacy Statement. I understand that WestOaks Orthopaedic offers the patient the opportunity to communicate and process medical claims and medical records by electronic submission. Signature of Responsible Party Date

4 Westoaks Orthopaedic Associates

5 MEDICAL HISTORY Name: Today's Date: Referred By: Age Height: Weight: 1. What problem, symptoms, or condition are you being seen for today? 2. WHEN was the first time the problem was noted (or if an accident: the time, place, and how you were injured)? 3. DESCRIBE the development of symptoms with approximate dates. Note the types of treatment(s) you have received, when you were treated, and who treated you. Has the problem gotten better, worse, or stayed the same over the last few days? 4. Note any prior occurrence of similar symptoms before the current condition began. 5. List other significant bone, joint, fracture or Orthopaedic problems in the past 6. Are you: [ ] Right Handed or [ ] Left Handed 7. What is your occupation and what are your physical demands?

6 SOCIAL HISTORY What is your Marital status _ Spouse s name. _ Do you have children? Do you smoke? N Y How much? Do you drink alcoholic beverages? N Y How Much? _ Do you have allergies to any medications? Please list: Are you taking any prescribed medications? Please list name, dose, & frequency: 1. _ 2. _ 3. _ Others: Are you taking any non-prescribed medications such as Advil, Motrin, Aleve, Aspirin, Nuprin? Please include vitamins and over the counter medicines: Please list name and frequency: 1. _ 2. _ 3. _ 4., _ Are you taking any herbal medications such as Ginkgo Biloba, Ginseng, and Silicon? Please list name and frequency Do you use any abusive substances? This is very important to insure your safety. Please specify:

7 PAST MEDICAL HISTORY Have you had the usual childhood illnesses, such as measles, mumps, chicken pox, etc. If so, which ones? Were there any residuals from any of these diseases? Have you had any major illness? If so, please list. Any residuals? Please list any surgeries you have had: Have any of your immediate family members had heart disease, cancer, TB, diabetes or osteoporosis? Any bleeding disorders (i.e., excessive bleeding), or other serious familial or hereditary disease? If so, please list below Have you ever been diagnosed with Osteoporosis or Osteopenia? N Y Have you ever had a bone density? N Y Where: When: Are you or have you ever taken medication for osteoporosis or osteopenia? N Y If so, please circle: Fosamax, Actonel, Boniva, Reclast, Zometa, Forteo, or Prolia? When and how long? Still taking? Do you take Vitamin D3 or Calcium? Y N How much?

8 Review of Systems HEAD, EYES, EARS, NOSE, THROAT AND MOUTH: Do you have any problems with your head in any way, such as headaches, dizziness or falling out spells? Are there any problems with your eyes, ears, nose, throat, mouth or teeth? CARDIOVASCULAR SYSTEM: Are there any problems with your heart? Do you have high blood pressure? If so, please explain. RESPIRATORY SYSTEM: Are there any problems with your lungs, shortness of breath, difficulty breathing, asthma, or wheezing? GASTROINTESTINAL SYSTEM: Are there any problems with your stomach, bowels, indigestion, etc.? GENITOURINARY SYSTEM: Are there any problems with your kidney, such as frequency, urgency, painful urination? How often do you get up at night to go to the bathroom? GYNECOLOGICAL SYSTEM: Are you having any difficulties with your menstrual cycles? Pregnant? Post-menopausal? When? 4

9 MUSCULOSKELETAL SYSTEM: Are there any problems with your muscles, bones or joints other than the present problem? Have you had a broken bone? N Y What bone & what age. _ CONSTITUTIONAL SYMPTOMS: Have you had recent history of weight loss, fevers or general feeling of weakness? If so, please explain. INTEGUMENTARY SYSTEM: Have there been any skin disorders? If so, please explain. ENDOCRINE SYSTEM Do you have diabetes, thyroid problem or pituitary disorders? If so, please explain. PSYCHIATRIC SYSTEM Do you have any psychological problem or are you under treatment? If so, please explain. HEMATOLOGIC/ LYMPHATIC SYSTEM Do you have or have you had any disorders of the blood or lymphatic system? If so, please explain. Thank You!! As a courtesy to our staff, patients, and physicians, please turn off your cell phone!

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