Single Divorced Widowed. Primary lnsurance lnformation. Employmen t lnformation. Secondary lnsunnce Company lnformation. Patient lnformation

Transcription

1 James lr. Weiss, f,,d. Date of lnjury or Onset: (mm/dd/yy) Today's complaint: Today's Date...J_/_ oplease Print Cleadvn Please Circle one: Manied Patient lnformation Single Divorced Widowed * ComplefD ALL Arcas that Appty in FUIL* Please Circle One: M F Patient Name: Last Firsl Middle lnitial Age Street address: City Apl # State Zip Code Home Phone: ( ) Cell phone:( ) Social Security Number: Please provide tte name of the doctor \i,ho refened you to our office? _ Date of Birth: Emergency Contact lnformatbn:. Relitioninip to Patient: spouse@er Primary carc physacian: (full name please) M / F Phone: ( \ Phone number. ( ) Employmen t lnformation Employer Name: Crty: Employer Address State Zip Code: Business Phone Number: ( ) Ext. Primary lnsurance lnformation lnsurance Company: Policyholder lnformation: rd# Group # Name: Last First Middle lnitial Sex: M/F DOB: _l_j_ Slreet address Apl. # City s18te zip code Employer Relationship to Patient Spouse Child Parent Other Phone: ( SSN: Secondary lnsunnce Company lnformation lnsurance Company Policvholder lnformation: td# Group # Name Last Firsl Middle lnitial Sex: M/F DOB: Skeel address Apt. i, City Employer Phone: ( Relationship to Palient: Spouse Child Parenl Olher state np code SSN: ]:: "*sh:i]: for providing accurate and complete insurance information for bilting purposes, a copy of your c rd, 8nd wcomp or other authorizalion

2 ll/orker's Comoensatio n I nfo rmation: Insurance Company Name: City State: Zip Code: Insurance Company Phone Number: Claim Adjuster's Name: Claim Adjuster's Phone Number: ) Claim Number: Date of Injury: Description of Work Accident: Aulomobile Insurtnce Informalion: (this is your insurance infbrmation) Automobile Insurance Company Name: C ity State: Zip Code: lnsurance Company Phone Number: Policy Number: Effective Date ofautomobile Insurance: I I Expiration D e: I / Policy Holders Name:_ DOB: SSN: Address City: State Zip Code:_ Do you carry Personal Injury Protection (PlP)?-- lnsurance Adjuster's Name City: State: Zip Code Insurance Adjuster's Phone Number: ( ) Claim Namber: Date of Injury: Location of Accident: Description of Automobile Accident: Attomey Name: Phone Number: Address City State: Zip Code: ( ) Fax Number:( ) l,, hereby ruthorize Dr. Weiss to spply for benelits on my behalffor covered services render d. I requesa piyment from _lnsurance Company, be made directly to the above named provider, I certify that the information I have reported with regard to my insurance coverage is correct!nd further authoriz the rel ase of any necessary information, including medical information for this or any related claim, to the above named billing agent, (or in the crse of Medicare part B benefits, to the Social Securily Administration and Herlth Care Financing Administration) and/or the insurance company named above. I permit a copy ofthis authorization to b uscd in place ofthe original, Either I ortheabove named c0rrier may revokethis authorization at anytime in writing. I also give consent for Dr. Weiss to render profcssional orthopaedic treatment. Todav's Dete Signature of Subscriber or Benefi cisry

3 Medical/Orthopaedic History Name: Todav's Date: Is your visit today due to a...? _ car accident _ work accident _accident _ other, please explain: This occurred during (check all that opply): Lifting _ Reaching - _ Pulling _ Squatting _ Pushing _ Hit by object _ Twisting _ Falling Not known PIease list all current medications: Name of Medication: Dosage Amount: How lone? Side Effects? Overall H th Review: Are you currently having, or have you had, any problems with the following? Eyes Ears, Nose or Throat Lungs or Breathing Problems Digestion Bowel Movement Bladder Problem Diabetes High Blood Pressure Bleeding Problems Balance Problems Numbness or Tingling Blackouts or Fainting Psychological Problems HIV/AIDS Polio TB Epilepsy Circle Describe all YES responses: Reviewed By: M.D. Date 7t02

4 Past Medical History: Surgeries and/or Hospitalizations: Year Complications? Have you ever had general anesthesia? Have you had any problems with anesthesia? Ifyes, please explain: Do you have any allergies (i.e., medicine, food, seasonal, etc.)? Famil! Hislor.v: Family Member: Grandmother (mom's) Grandmother (dad's) Grandfather (mom's) Grandfather (dad's) Mother Father Sister or Brother Sister or Brother Sister or Brother Sister or Brother Alive or Deceased (please circle) Age Health Status or Cause of Death Social Histor,v: Do you work at home? _ Are you a student? _ Occupation: Ifyes, what grade are you in? Are you...? _ Married _ Single _ Divorced _Separated _ Widowed Do you have children? _ Ifyes, how many? _ Do you live alone? _ Do you exercise? _ lfyes, what kind? Are you on a special diet? _ If yes, what kind? Do you have a history of substance abuse? Ifyes, please describe: Do you drink alcohol? How often? _ Daily _l-2 week _ l-2 month Are you currently smoking? _ Ifyes, how many packs per day? _ How long? _ l-2 year Reviewed By: M.D. Date 7/02

5 James Weiss, M.D. Specialist in the Practice of Orthopedic Surgery Executive Park Terrace Germantown, MD 208'14 Phone: Fax: : 8401 Connecticut Ave., Ste 220 Chevy Chase, MD Phone: Fax: NOTICE TO ALL PATIENTS In order for our billing department to be able to submit claims correctly, we need our patients to be aware of their insurance company's guidelines and restrictions. You can and will be billed for these service rendered. It is your responsibility to know ifreferrals are required from your primary care physician. Ifyour insurance denies this visit res ble on a fee service Please sign the following waiver. WAIVER I,, am fully aware of my insurance guidelines and or restrictions. I have chosen to receive care at this oflice; therefore I am responsible for all claims denied by my insurance company for lack of referrals, authorizations, etc. Siped Dated

6 James Weiss, M.D. Specialist in the practice of Orthopedic Surgery Executive Park Terrace Germantown, MD Phone: Fax: Connecticut Ave., Ste 220 Chevy Chase, MD Phone: Fax: Acknowledgement of Receipt of Privacy Practices (To be filled in patient's medical record) I have been presented with a copy of the Notice of Privacy Practices, detailing how my health information may be used and disclosed as permitted under federal and state law, and outlining my rights regarding my health information. sigred- Date: Relationship (ifnot signed by patient): I wish to place the following restrictions on disclosure of my health information: Internal Use Only Ifpatient/patient's representative refuses to sign acknowledgement, please document date and time notice was presented to patient and sign below. Presented on (date and time):_ By (name and title):_

7 JAMES M. WEISS, M.D. FINANCIAL POLIGY '13245 Executive Park Terrace Germantown, Maryland Connecticut Avenue Suite 220 Chevy Chase, Maryland 208'15 'L The patient is responsible for payment which is required at the time of service 2. We accept cash, check, Visa or MasterCard 3. lf you have insurance coverage, you will be expected to pay a percentage of the bill at the time service is rendered, e.9., your Co-pay. You will be held responsible for any additional charges not covered under your policy. Should a credit balance occur, we will refund any overpayment promptly. 4. lf James M. Weiss / Physician Associates does not participate with your insurance, you will be responsible for the payment at the time of your visit. For your convenience, we will submit your claim to your insurance company on your behalf and your insurance will reimburse you directly. 5. There will be a charge for all forms filled out, whether by the office staff or the physician. 6. Appointments must be canceled at least 24 hours prior to the appointment time to avoid additional charges to your account. lf your appointment is scheduled for a Monday, any cancellation must be made the preceding Friday. 7 Returned checks and accounts with balances more than 30 days old may be subject to additional fees, including a monthly late charge of 2%. Billing statements are sent out monthly. James M. Weiss / Physician Associates reserves the right to pursue legal remedies in Maryland District Court for accounts more than g0 days old. 8. Patients are responsible to provide James M. Weiss / Physician Associates with accurate insurance information to ensure that claims are processed expeditiously. Notice to Medicare and HMO/ppO patients Certain services provided by this office are considered not-covered under your insurance policy will be required to pay for any such services when rendered. You Our office does not mail or fax referrals to specialist offices unless it is a medical emergency. I understand and acknowledge the above financial policy. Patient Name (Please Print) Patient Signature Date Should you have any quesfions or concems regarding these policies, please feel free to contact our billing staff for asslsfance.

8 James M. Weiss, M.D. Specialist in the Practice of Orthopedic Surgery Executive Park Terrace Germantown, MO Phone: Fax: Connecticut Avenue # 220 Chevy Chase, MD Phone: Fax: 30'l I am requesting treatment in Dr. James Weiss' Patient's Name Office for any orthopedic injuries sustaine<i rs a result ofa I have engaged an Attomey _ to represent my interests Attorney's Name relating to this injury. I have the option of submitting my incurred charges for care rendered from your office through my private health insurance Health Insurance I instruct your office/billing service to bill my insurance for all charges that result from my care by Dr. James Weiss' relating to this injury YES or NO. If I now choose not to (Circle One) use my health insurance for this injury (I circled NO) then I understand that I of claim timely filing limitations) request later in my heatrnent that my insurance be billed especially in the instance where my case was not successful (my attomey v/as not able to obtain funds to pay ibr,ny medical care). I understand that I will ultimately be responsible for all incurred charges for treaftnent rendered by Dr. James Weiss. Sigrrature of Patient/Guardian Date

9 James M. Weiss, M.D. Specialist in the Practice of Orthopedic Surgery ' Executive Park Terrace 8401 connecticut Ave., ste. 220 Germantown, MD Chevy Chase, MD Phone: 'l Phone: (30I) 98&6939 Fax: Fax: (301) Assignment and Authorization You are heteby authorized to drsclose and/or Armish my att.mers, any and all medical informatioo, recotds, arrd bills in your posses;ion (iocluding aoy and all medical information, records, and bills ftom any othet health care ptovidet) which drey request io refereoce to any illnesses and injuries suffered by (wo*ers cornp iniury, Auto rcjdent injuly, od'. ) Including but not limited to, the i.oiuties v'hich were sustained on P"t") This authorizatioo to obtain medicd tecords and inforoatioa contained in this paregsaph expires ooe yeat ftom this &te uoless extended ot teoewed by me. I futthet irrevocably assign to you, and authorize and &ect said attomeys to pay from the proceeds of any recovery io my case all reasonable fees for services provided by you, induding fees for the preparatioo and testimooy as a Esult of the injuty hetetofote mentioned. I uadetstand -, that tlis ia no way relieves me of my personal pimary obligation to pay for such services, and that the signing of this form does not prohibit customary bill by you. All bills shall be paid prompdy in &e usual marurer. It is futthet undectood that the statute of limitations on this Stete is three (3) yeas ftom the time said services $!e last perfomed, and I firrther rmdcrstaad that because of loog delays io r.i^l dockets, many cases are not ttied or settled uotil a date which is beyond thc thtee (3) years after the last service was performed. In view of this,i hereby agree that the statute of limitations u,ith respect to any daim for services meotioned above will oot begin to run until there is a deqial io wdting by us of aoy balance claimed to be due aod owing to you by me, In addition, the patient agees that ifpayraent is.rot received in a timely manner withio 30 days after settlemeat and collection proceedings aust be instituted by Dr. Weiss, the patieat shall pay all costs ofcollectioo plus reasonable attomey fees and prejudgruent interest. V/itness Date Sisnature Addtess Rclationship to parienr_ The undersigaed attomey for tie patient referred to above heteby agtees to comply fully with the foregoing authorization aad assigament, and agrees to advise tle named health care providet in wtiting the status of the clairo ofthe patietrt cr'ithin ten (10) days ofthe tequest. I agtee to noti-s tlle physician ifi discontinue reprcseotation of the client. Ptint Name- Date- Prht name rrorney Signarure_ ^ l.rm Name Address