Patient Name: Date of Birth: / / Last First Middle I. Home #: Cell #: Work #: Address: Primary Care Physician: Phone: Insurance ID #: Group #:

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1 Patient Name: Date of Birth: / / Race: White Black/African American American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Other Ethnicity: Not of Spanish/Hispanic Descent Spanish/Hispanic Primary Language: Home #: Cell #: Work #: Address: Address: _ City: State: Zip: Referring Physician: Phone: Primary Care Physician: Phone: Pharmacy: Phone: Emergency Contact: Phone: Is This a Work/ Auto Related Injury YES NO (If Yes Go To Page 2) Primary Insurance Company: Insurance ID #: Group #: Policyholder s Name: Date of Birth: / / Relationship to Patient: Address: _ City: State: Zip: Home Phone_ Work Phone Employer: _ Secondary Insurance Company: Insurance ID #: Group #: Policyholder s Name: Date of Birth: / / Relationship to Patient: Address: City: State: Zip: Home Phone_ Work Phone Employer: _

2 PLEASE COMPLETE THIS SECTION IF THIS IS A WORK RELATED INJURY OR AUTO ACCIDENT: Patient Name: Work Related Injuries Date of Injury: / / Claim #: Employer: County located in: City: State: Zip: Phone: Contact Name: Phone: Auto Accident Date of Injury: / / Claim #: Auto Insurance Carrier Insurance ID#: Address: City: State: Zip: Phone: Contact Name: Phone: Assignment Of Benefits For consideration received, I do hereby assign to THE ORTHOPEDIC INSTITUTE OF NEW JERSEY. all my rights and interests in the personal injury protection portion of any and all applicable automobile insurance policies under which I may be entitled to benefits including but not limited to Personal Injury Protection Benefits. This assignment is given with respect to all treatment, care, and diagnostic testing provided by THE ORTHOPEDIC INSTITUTE OF NEW JERSEY. By assigning my benefits I expressly agree that the following rights are assigned to THE ORTHOPEDIC INSTITUTE OF NEW JERSEY. 1. The right to collect from the insurer directly payment for any services rendered by THE ORTHOPEDIC INSTITUTE OF NEW JERSEY with respect to Personal Injury Protection Benefits. 2. The right to file a lawsuit or arbitration as provided by applicable law against the insurance company in the name of THE ORTHOPEDIC INSTITUTE OF NEW JERSEY as assignee and to designate an attorney of THE ORTHOPEDIC INSTITUTE OF NEW JERSEY s choosing for the purpose of filing said lawsuit. 3. I agree to fully cooperate with the Assignee in the prosecution of the personal injury protection claim against the applicable insurance carrier, including full cooperation with the attorney chosen by including but not limited the appearance at any deposition and appearance at trial and/ or EUO. Voluntary Physician s Lien I hereby agree to provide an irrevocable Lien to THE ORTHOPEDIC INSTITUTE OF NEW JERSEY against any settlement, judgment or verdict arising out of my automobile accident for which I am receiving treatment. I agree that pursuant to the terms of this agreement I may not rescind this document and that a recession will not be honored by my attorney. I further instruct that in the event another attorney is substituted in this matter, my new attorney shall honor this Lien. Upon settlement, judgment, verdict and prior to the disbursement of any funds to myself, I hereby direct my attorney to pay to THE ORTHOPEDIC INSTITUTE OF NEW JERSEY any and all sums of money that may be due and owing THE ORTHOPEDIC INSTITUTE OF NEW JERSEY. Furthermore, I fully understand that I am primarily responsible for all treatment rendered to me by THE ORTHOPEDIC INSTITUTE OF NEW JERSEY and all bills which I may incur. Patient Signature: Date: / /

3 Past Medical History: Please List surgeries you have had: Date: / / / / HISTORY: Please check any applicable diseases/disorders. If these diseases/disorders runs in your family please check and indicate the relative in the space provided. Heart disease Arthritis Hypertension Alcohol Abuse Diabetes Drug Abuse Cancer Other SOCIAL HISTORY: Marital Status: Married Single Separated Divorced Widowed 1. Do you Smoke? 2. Do you drink alcoholic beverages? No Yes If yes: Packs/Day Quit When? No Yes If yes, per week? 3. Do you consume caffeinated beverages 4. Do you use or have you used street drugs? No Yes If yes, per week? EMPLOYMENT STATUS: No Yes If yes, what kind and when? 1. Job Title/Occupation: 2. Please check current work status: Working Full Time Working Part Time Working Light Duty: Retired/Not Working Off Duty Due to Injury Hours worked per day Days worked per week Reason for Visit When did your symptoms appear? Is this condition getting progressively worse? Yes No Unknown Rate the severity of your pain on a scale from 1(least pain) to 10(severe pain) Mark the drawing below to show your pain Type of pain: Sharp Dull Throbbing Numbness Aching Shooting Burning Tingling Cramps Stiffness Swelling Other How often do you have the pain? Is it constant or does it come and go? Does it interfere with your: Work Sleep Daily Routine Recreation Movements those are painful to perform: Sitting Standing Walking Bending Lying Down Current Medication Allergies

4 Financial Policy for TOINJ Patients and Commercial Insurance Companies Thank you for selecting The Orthopedic Institute of New Jersey as your health care provider. It is our sincere desire to provide you with the best possible medical care. This involves mutual understanding among the patients, healthcare providers and staff. We encourage you, our patient, to discuss any questions you may have regarding our professional fees, this financial policy and your responsibility. Patient Responsibility: 1. Your insurance company makes final determinations as to coverage and sets the terms and conditions that govern your relationship with the insurance company and our relationship with that same insurer as well. We do not make the rules. 2. Payments that your insurance company deems are your responsibility, such as office visit co-pays, deductibles and co-insurance become your patient responsibility and these amounts are due and payable to TOINJ and constitute an important source of revenue to support the practice. 3. In the event that patient responsibility exceeds $300 our Patient Relations officer will review the account with you to make payment arrangements and to ensure continuity of care. Our Patient Relations Officer is Ms. Veronica ( Ronnie ) Tarulli and she can be reached at (908) We request that you place a credit card on file with us to guarantee payment. The credit card is stored safely and will be used to process your patient responsibility in a responsible manner, saving us all time and expense. 5. If scheduled for surgery, our policy is to collect your surgery patient responsibility prior to surgery. Our scheduler will call you with our good faith estimate to discuss with you and ask for payment up front. TOINJ only charges for physician and physician assistant fees, facility fees and anesthesia fees are payable to the facility/anesthesiologist as the case may be. 6. Patient responsibility is due on demand and we take cash, check and all major credit cards. Upon request, we will make short-term payments plans to satisfy balances but only if you provide a valid credit card on file and within the expiration date of that credit card. All returned checks will be subject to $50.00 return reprocessing and administrative fee. 7. We will send you a statement every month and phone call reminders detailing charges. If you have any questions, please call our Financial Counselor, Ms. Pauline Gaudio at (908) , she will be happy to assist you. 8. If we are forced to start collection proceedings, we will charge your account for reasonable collection costs including attorney fees, court costs and interest on the balance as allowed by law. Other Matters: If your plan requires a primary physician referral, please provide same at the time of visit, most primary physicians will provide you with a referral letter or they may even be able to send the referral electronically. Please inform the office of ANY secondary coverage. Insurers may not pay a claim at all or you may end up liable for the charges if the coordination of benefits is not complete, we are trying to help you. We are unable to change diagnosis codes and/or procedure codes to meet the reimbursement requirements of your plan for a medical service specifically excluded by your policy. I authorize payment of benefits be made on my behalf to The Orthopedic Institute of New Jersey for any services furnished me by the provider. Additionally, I authorize TOINJ to furnish information from my medical records pertaining to my treatment as requested by other healthcare providers for my continued care and treatment. I have been presented with a copy of TOINJ s Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state law. I have read the above and agree that I am ultimately responsible for the balance on my account for any services plus reasonable collections costs including attorney fees, court costs and interest on the balance as allowed by law. Patient Name Patient Signature Date / /

5 Acknowledgement of Hipaa Privacy Notice and Designation of Disclosure Acknowledgement of Practice s Notice of HIPAA Privacy: I have received a copy of the Notice of HIPAA Privacy for The Orthopedic Institute of New Jersey. Patient Name Patient Signature Date / / Designation of Certain Relatives, Close Friends, and Other Caregivers: I agree that the practice may disclose certain of my health information to a family member, close personal friend or other caregiver, since such person is involved with my health care or payment relating to my health care. In that case, the practice will disclose only information that is directly relevant to the person s involvement with my health care or payment relating to my health care. I wish to be contacted in the following manner (check all that apply): Appointment Information Home Phone (Include Auto Call) Mobile Phone (Include Auto Call) Mobile Text (Include Auto Call) Work Phone Via Mail Via Medical Information Home Phone (Include Auto Call) Mobile Phone (Include Auto Call) Mobile Text (Include Auto Call) Work Phone Via Mail Via I designate the following person listed below as persons involved with my health care or payment relating to my health care for the purpose of the practice making the limited disclosures described above. I understand that I am not required to list anyone. I also understand that I may change this list any time in writing. Print Name Relationship Phone Number Print Name Relationship Phone Number The following person(s) are not authorized to receive my patient health information: Print Name: Print Name:

6 Guidelines For Treatment With Controlled Substance Medications This document is about your use of controlled substance medications prescribed by your physician. These medications are being used to relieve pain and improve function. Most patients who use these drugs find them very helpful and use them without problems. We have found that it helps patients when we establish a clear understanding at the beginning of therapy concerning the use of these medicines. This document should help you to understand our medication policies and your role as part of the pain treatment team. You need to have your primary care physician or family doctor sign the document acknowledging that you are receiving pain medications from our clinic. While your physician is not obligated, he or she can decide to take over prescribing the pain medications once you are on a stable dose; however, this must be done with our consent. These guidelines apply to all controlled substances including opioid pain medicines. Medications refers to these substances. These guidelines do not apply to other drugs used for other purposes. Provider refers to the physician or other medical professional who has agreed to prescribe your medications. 1. You are responsible for your medications. You are expected to take them only as prescribed by your provider. Please communicate any questions or concerns, such as side effects or dose questions, to your provider or nurse. 2. All your pain medications should be prescribed only by your main pain management doctor. You should get them from a single pharmacy (provide information at the end of document). You should not obtain medications from other doctors or pharmacies, unless you are a patient in the hospital. You should tell any hospital or emergency room doctors that you receive pain medications from your provider. Have your dentist contact your provider before giving you medications. These guidelines are designed to protect you from the danger of receiving too much medication. 3. You may not change your medication dose without first getting your provider s permission. Changing the dose without permission may endanger your health. Your provider will give you instructions about what to do if the office is not open when you need advice. 4. You are expected to make sure that your prescriptions are filled on time. You will be given enough medication to last a fixed amount of time, usually 30 days. Refills can only be given during regular office hours, in person, during a scheduled visit. To avoid interruption in your medications, please schedule regular appointments for medication refill. Make sure that you schedule each appointment far enough in advance to avoid running out of medications. Prescriptions cannot be filled early. Prescriptions will not be sent by mail, faxed, or filled by telephone request. 5. Keep your pain medications in a safe and secure place. We advise that you keep them in a locked cabinet or safe. You are expected to protect your medications from loss or theft. Stolen medications should be reported to the police and to your provider immediately. If your medications are lost, misplaced, or stolen, your provider may choose to taper and discontinue the medications. You may also be asked to provide a police report to your provider. 6. You may not give or sell your medications to any other person under any circumstances. If you do so, you may endanger that person s health. It is also against the law. 7. You should not use alcohol or illegal drugs while taking these medications. You should not use sleeping pills, cold medicines, or other medications that might cause drowsiness, dizziness, or changes in thinking unless you first discuss them with your provider. 8. You should not drive or operate heavy machinery if you feel tired, mentally foggy, or are experiencing other side effects from your medications. It is your responsibility to keep yourself and others from harm. 9. It is sometimes necessary for your provider to check your medication levels. At such times, you may be asked to provide blood and/or urine specimens for testing. Refusal of being tested could result in being discharged from the opioid portion of the office. Not all insurance companies cover this testing done in our office. If your insurance does not cover this test you will be responsible for the charge of administering this test which is $25 to be paid at the time of the test. Our front desk staff is available if you should have any questions about your specific insurance coverage. 10. Your medications are only a portion of a larger treatment plan. We ask that you participate fully in treatment and follow your providers advice regarding physical therapy, psychotherapy, vocational rehabilitation, counseling, other medications, or other prescribed or recommended treatment.

7 11. So that your other doctors understand and can help with your treatment, we ask that you let your provider contact other providers and pharmacists about your use of medications. 12. These medications are very helpful to many patients but are not right for everybody. It is sometimes necessary for a provider to stop prescribing these medications for a patient. Your provider might choose to taper and discontinue your medications if: The treatment is not helpful. The treatment loses its effectiveness. You have serious side effects from the medication. You become less able to function physically, socially or emotionally as a result of the treatment. You are unable to follow the other guidelines listed in this document. 13. If your medications must be stopped for any reason, your provider will taper you off the medications (slowly decrease the dose) in controlled fashion to avoid withdrawal symptoms. Your provider may consult a specialist if s/he feels additional help is needed to accomplish a safe taper. 14. For women only: Your use of these medications may adversely affect a fetus if you are pregnant, or a child if you are breastfeeding. If you are pregnant or breastfeeding now, or if you are considering becoming pregnant, you should discuss your use of these (and any other) medications with your primary provider or obstetrician. 15. Please be advised, by signing below, you authorize our office to retrieve your current prescriptions using SureScripts technology. 16. The physician may prescribe medications depending on what the physician deems as appropriate and indicated. This may or may not be the same medication other physicians have prescribed By signing below, you acknowledge that you have received, read, understood and agree to follow the following guidelines. Also, you agree that failure to follow these guidelines can result in discontinuance of medications. Patient Name Signature Date Payments for the office visit are nonrefundable Thank you. We look forward to working with you to help relieve your pain and improve your function.