PATIENT REGISTRATION FORM

Transcription

1 Welcome to our office, and thank you for letting us take care of you! PATIENT REGISTRATION FORM (Please do not leave blank lines: place a hyphen (-) or N/A in any question that does not apply to you. Today s Date: Primary Care Physician: Primary Care Physician phone no: INFORMATION Patient s Last Name: First: Middle: Marital status: Single Mar Div Sep Wid Is this your legal name? Patient address: If not, what is your legal name? (Former name): Birth Date: Age: Sex: M F Can we communicate with you via ? Social Security Number: Home phone no: Cell phone no: Alternative no: Primary Street Address: City: State: ZIP Code: Insurance carrier: ID #: Effective Date: Secondary/Supplemental carrier: Are you the policy holder? Relationship: Date of Birth: Contact no: Name of the policy holder: Is this case (or will it be) involved in litigation? Date of injury: Adjuster or case Mgr name: Phone no: Is this case a Worker s Compensation claim? (work related) Fax no: Were you referred here by Worker s Compensation? Chose clinic because/referred to clinic by: Dr. Insurance Plan Hospital Lawyer Employer Friend Pharmacy name and location: Pharmacy phone no: IN CASE OF EMERGENCY Name of emergency contact: Relationship: Home phone no: Work phone no: I hereby authorize payment directly to Physicians for the Hand of all insurance benfits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered for me or for my dependents. I authorize the doctors and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of my signature on all insurance submissions. I authorize a copy of this document to be used in place of the original. I have read and agreed to the above. Patient/Guardian signature Date

2 Please answer to the following questions to the best of your ability. List any allergies/reactions ne List all medications ne Iodine Penicillin Sulfur Drug Allergy: Food/ Environmental Allergy: Shellfish Nuts Pollen Dust Mold Latex History to all Do you smoke? How much? Do you drink alcohol? How often? Do you get the shakes if you go without drinking? Do you use any other drugs? Are you pregnant? Unsure Do you have (or have you had) any of the following medical conditions? ne High Blood Pressure Pneumonia Stomach Ulcers Migraines Stroke Rheumatoid Arthritis High Cholesteral Asthma Blood Clots Psychiatric Osteopenia Diabetes Bronchitis Phlebitis Paralysis Osteoporosis Heart Attack Emphysema Urinary Tract Infection Seizures Spinal Stenosis Irregular Heart Beat Pulmonary Embolism Birth Defect Depression Arthritis High Thyroid Low Thyroid HIV/AIDS Hepatitis Tuberculosis Enlarged Prostate Cancer: Radiation Chemotherapy Blood transfusion? Reaction? Any other medical problem(s) not listed? Previous Surgeries? ne Tonsils Thyroid Stomach Bowel Heart Prostate Cosmetic Appendix Ear se Throat Galt Bladder Vascular OB/Gym Breast Orthopedic Surgeries Other Constitutional Fevers Fatigue Muscle aches Weight gain Loss of appetite Cardiovascular Chest pain Heart skips a beat Lightheadedness Fainting Review of Systems: During the past 2 weeks, have you experienced any of the following? chills loss pressure Ear/se/Throat/Neck Hearing Loss Nasal Congestion Bloody se Sore Throat Dental Problem Gastrointestinal Nausea Diarrhea Constipation Fainting vomiting Cough Respiratory Difficulty breathing Wheezing Chest pain when taking a deep breath Hormonal/Endocrine Abnormal menses Hot Flashes Dry Skin Excessive Sweating Numbness Weakness Headaches Dizziness Memory problem Pain Neurologic Discharge Eyes Visual disturbance Eyelid drooping to all listed. Genitourinary Painful urination Blood in urine Side/flank pain Urine incontinence Urinary frequency urgency Musculoskletal Neck Back Muscle pain Difficultly walking Joint pain swell red Stiffness Deformity Leg Pain Cramping Abdominal Pain Thin Hair Shoulder Arm Elbow Leg Swelling Stool Incontinence Heat Cold Intolerance Wrist Hand ( Lt Rt) Increased Thirst appetite Hip Thigh Knee Leg Foot ( Lt Rt) Ankle

3 >Reason for today s visit: Location: CHIEF COMPLAINT FOR TODAY S VISIT Left Right Both >Which is your dominant hand? >What date did the problem begin? Left Right Ambidextrous >How long have you had this problem? Years Months Days >Are there any hobbies/activities you enjoy that this problem is keeping you from doing? Briefly describe how the problem started. Injured at work Car accident Fall >Please circle where you have pain or problem. Medical Records pertaining to complaint. ne t treated by another physician Have you had any If you did not bring them please tell us where you went so we can obtain this information. testing(i.e. MRI,CT Scan, X-Ray, Nerve Conduction, etc.) for the problem. Name: Address: Did you bring your test photos, CD, or results with you today? City: State: Zip: Phone: Fax: Date of Test: Have you been seen or treated by another physician for this problem? Name: Address: City: State: Zip: Did you bring your medical records from this office today? Phone: From: Surgery: Date(if applicable); Until: Fax: Procedure done: We are in the process of creating a newsletter for our patients with interesting health information. Would you be interested in receiving this ? The information I have given above is complete and accurate, to the best of my knowledge. As will all medical records, the information that I have provided will be confidential. x Patient/Guardian signature x Date

4 Patient Financial Policy Thank you for choosing The Ouellette Group Physicians for your orthopedic care. We sincerely hope that by sharing our financial expectations we will strengthen the practice-patient relationship and keep the lines of communication open. General Information Your insurance policy is a contract between you and your insurance company. You are responsible for understanding the terms of your coverage and for any amounts not covered by your insurer. Referrals and/or authorizations are your responsibility: they must be obtained prior to your office visit. Your appointment will be rescheduled if you do not have this information. It is your responsibility to resolve disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, and reporting of prior existing condition information. Your balance is due within 30 days of receipt of a statement from us regardless of any dispute with your insurance company. While our billing professionals will do all they can to help our patients in communication and negotiating with their insurance plan, any question regarding coverage, benefits, or payment for services provided is the patient s responsibility to resolve. It is the patient s responsibility to notify the office of any change of address, phone, employment, or insurance coverage in a timely manner. We reserve the right to report delinquent accounts to credit bureaus, assess a collection fee, take other collection action, or terminate you as a patient of this practice. Payment is Due at the Time of Service We accept cash, checks, and credit cards. All co-payments, deductibles, co-insurances, and non-covered services are due at the time of service. Proof of Insurance You must provide your insurance card and photo ID at each appointment. We participate with most insurance plans. Please check with your insurer prior to your appointment. We do not participate in any Medicaid insurance plan, nor do we file insurance in the case of auto or liability insurance. These situations are handled under our Self-Pay policy. It is your responsibility to provide complete insurance health insurance information. Claims denied due to the failure to provide timely, accurate and complete insurance information are your responsibility.

5 Self-Pay Accounts Payment is expected at the time of service for Self-Pay accounts. We will do our best to give patients an estimate of the charges in advance of the appointment. This estimate is subject to change based on the treatment recommended and provided by the physician and therapists. A self-pay discount is offered when payment is made at the time of service. If you are unable to pay in full at the time of service, please contact out Billing Office to make payment arrangements. Foreign Insurance We file claims to insurers with claims addresses in the United States. Patients with insurers outside of the United States are treated under the Self-Pay policy. Occupational Therapy Services We provide occupational therapy services in our offices. Insurers apply separate co-pays, deductibles, and co-insurance to these services. Often a key component of therapy services may include the fabrication of a custom splint for you. Insurers consider splints fabrication as outpatient services (versus physician office) and therefore your outpatient co-pay and/or co-insurance may apply. Certain supplies used in our occupational therapy services are non-covered by insurance and you will be responsible for the normal cost of the supplies. We do our best to inform the patient in advance when these supplies are used in your care, but the patient is ultimately financially responsible for services and supplies not covered by insurance. Medical Supply Charge To save clerical and recover costs of miscellaneous medical supplies used in our practice, a fee of $40.00 will be collected for each surgery and a fee of $10.00 for each office procedure. These are for charges not covered by insurance carriers. o o Procedures, including but not limited to: Cast application; Cast removal; Cast change; Suture removal; Injections Partial list of materials not covered: Bandages, gauze, needles, syringes, lidocaine, clips, fasteners, sutures, scissors, surgical trays I have read the Patient Financial Policy and I agree to abide its terms Patient Signature Date: Patient Name: Date of Birth:

6 I have read the Privacy Policy and/or I have been given the opportunity to review it. I agree that you may leave messages containing Protected Health Information on the following numbers: Home/cell/office/other Home/cell/office/other I agree that you may discuss my Protected Health Information with the following people: Relationship Relationship Relationship I understand that I can change these notifications anytime by given written notice. Patient signature Date: Printed Name Date:

7 Advance Beneficiary tice of n-coverage for Commercial Carriers Patient Name: Insurance Carrier: Date: Dear Patient: You are receiving this notice because your insurance company may not pay for all of the services that you receive during your Office Visit/Occupational Therapy treatment/surgery. Insurance does not pay for everything, even some care that you and/or your healthcare provider have a good reason to think you need. There are limits on benefits for services provided and maximum number of visits allowed. We will verify your insurance regarding your benefits for Office Visit/Occupational Therapy treatment/surgery. Verification of insurance does not guarantee payment so we cannot guarantee that information to you. You are responsible for payments on uncovered items agreed upon by you and your healthcare provider. Please choose below: I agree to the above and will pay out of pocket for uncovered services. I agree to pay for uncovered services up to $ without further consent. I do not agree to pay for uncovered services and I will limit my care within that statement. It is your responsibility to know and understand your insurance benefits. Please contact your carrier if you have any questions regarding your policy or its limits and/or exclusions. Patient Signature:

8 Medical Supply Charge To save clerical and recover costs of miscellaneous medical supplies used in our practice, a fee of $40.00 will be collected for each surgery and a fee of $10.00 for each office procedure. These are for charges not covered by insurance carriers. Procedures, including but not limited to: Cast applications; Cast removal; Cast change; Suture removal; Injections Partial list of materials not covered: Bandages, gauze, needles, syringes, lidocaine, clips, fasteners, sutures, scissors, surgical trays Signature

9 Commercial Insurance Information Dear Patient: We understand how confusing the world of health insurance can be, so this letter is to help clarify some of the most commonly asked questions. Making an Appointment: You will be asked to verify your current insurance carrier this will ensure the physician is contracted with this particular health insurance carrier and your specific health insurance plan. Insurance Eligibility: Your insurance eligibility with this office is dependent upon two factors: 1. Your active status with your carrier. 2. The physician s level of participation with each health plan. Keep in mind the provider directories are not proof of physician participation. Verification of Insurance: We verify insurance for all patients and their respective plans. Arriving for Your Appointment: Make sure you have your current/active insurance card and photo ID Referrals: If required by your policy you are responsible for obtaining a referral. Payment Process: The provider (the physician) must be contracted with your insurance carrier and your specific plan for payment to be received and for you not to receive a bill. If we are contracted you are responsible for the co-payment Co-payments are due at the time of service If we the provider(physician) is not contracted with your specific plan you might have Out-of-Network benefits o Based on your specific plan, Out-of-Network benefits allow you to see the physician under cost sharing arrangements (i.e. 80/20, 70/30, or 60/40) o Based on your specific health plan, you are responsible for your portion of the Out-of-Pocket cost for services rendered at the time of service. Deductibles: are your predetermined responsibilities for medical services provided. If applicable, deductibles must be met prior to the physician receiving any payments from the insurance companies for services rendered. Deductibles are usually different for In-Network and Out-of-Network benefits. They also vary based on your coverage (i.e. individual, individual/spouse/child and/or family). If you have a deductible you are required to meet that dollar amount as part of your contract with the insurance carrier. We do understand many plans have high deductibles and we are willing, prior to services rendered, to discuss a payment plan with you. Our billing department will provide you with a financial agreement. It is your responsibility as the insured to understand your plan. If you need clarification of your plan, we will set up a conference call between the carrier, us (provider) and you the patient to answer any questions. Thank you,

10 Occupational Therapy benefits notification The Ouellette Group Physicians offers Occupational Therapy Patient Name: Date: Occupational Therapy is a separate and identifiable service offered by this office. Therapists are providers that are contracted separately from your physician. Occupational Therapy has plan limits based on your insurance carrier. There are separate co-pays for Occupational Therapy; Co-Pays are due at time of visit. There are separate authorizations needed for you to your have your occupational therapy treatment at our office. We obtain these authorizations for you. If you receive any questionnaires at home regarding your treatment plan please fill them out and return to your insurance carrier; without that data payment can be delayed and result in a bill to you. If you are a surgery patient your Occupational Therapy visits are not part of the global treatment and are not considered post op visits. Your first OT visit is customarily the day after surgery. At that visit the bandage is charged and mobility is assessed. There is a charge for this visit as well as all subsequent visits. Some supplies and orthotics ordered by your physician may not be covered by your insurance plan. You are responsible to make those payments. Your health and wellness is our primary focus. By addressing the financial arrangements now we can alleviate any concerns and allow you to focus on healing. Payment arrangements can be made prior to treatment. Please ask to speak with the manager about this option. I will need to arrange for a payment plan. I agree to the above and understand my responsibility in accordance with my insurance carrier. It is your responsibility to know and understand your insurance benefits. Please contact your carrier if you have any questions regarding your policy or its limits and/or exclusions. Patient Signature: