PATIENT INFORMATION PATIENT ETHNICITY / RACE SPOUSE INFORMATION EMERGENCY CONTACT

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1 Conway Orthopaedic & Sports Medicine Clinic, PA 550 Club Lane Conway AR, Account #: : Patient's Name: Patient's Street Address: Apt #: of Birth: Patient's Mailing Address/PO Box: Sex: [ ] Male [ ] Female Social Security Number: Home Phone: Employer: Marital Status: [ ] S [ ] M [ ] W [ ] D Address: Cell Phone: Work Phone: Referring Physician: Phone Number: Family Physician: Name: [ ] Hispanic or Latino [ ] Not Hispanic or Latino [ ] American Indian or Alaskan Native [ ] Asian [ ] White [ ] Native Hawaiian or other Pacific Islander [ ] Black or African American of Birth: Social Security Number: Home Phone: Cell Phone: Employer: EMERGENCY CONTACT: (Someone not living with you) Work Phone: Relationship to Patient: Contact Phone: Cell Phone: Name: Address: Relationship: Social Security Number: of Birth: Home Phone: Employer: Marital Status: [ ] S [ ] M [ ] W [ ] D Work Phone: Cell Phone: [ ] Primary Coverage [ ] Workman's Comp (check one) [ ] Secondary Coverage Company: Address: Phone: Ethnicity: Race: Name of Insured: Insured's of Birth: Company: Address: Phone: Name of Insured: Insured's of Birth: Policy Number: Group Number: Policy Number: Group Number: Insured's Social Security Number: Relationship of Patient to Insured: The above information is correct to the best of my knowledge. PATIENT INFORMATION PATIENT ETHNICITY / RACE SPOUSE INFORMATION EMERGENCY CONTACT RESPONSIBLE PARTY IF PATIENT IS A MINOR (TO BE COMPLETED BY PARENT PRESENT WITH CHILD TODAY) INSURANCE INFORMATION Insured's Social Security Number: Relationship of Patient to Insured: Signature

2 Conway Orthopaedic & Sports Medicine Clinic, PA 550 Club Lane Conway AR, Name: Account #: : REASON FOR TODAY'S VISIT What part of the body are you being seen for today? (circle one) Right Left Did you have an accident? (circle one) Yes No Is the accident related to : (circle one) Work Auto Other ***** IF AUTO RELATED, SKIP TO NEXT SECTION ***** If other, pleas explain: When did the accident occur? Month: Day: Year: Where did the accident occur: Did you go to the Emergency Room? When? Where? Brief Description of the accident: IF YOUR INJURY WAS DUE TO AN AUTO ACCIDENT, PLEASE COMPLETE THE FOLLOWING: Where did it occur? When did the accident occur? Month: Day: Year: Did you go to the Emergency Room? When: Where? Were you: (circle one) Driver Passenger Pedestrian Please explain the details of the auto accident: My auto insurance company is: Adjuster's Name: Insurance Company's Phone Number: Insurance Company's Address: Claim or Policy Number: Have you hired an attorney because of the accident? Attorney's Name: Attorney's Address: Phone: The above information is correct to the best of my knowledge. Signature

3 Account # : Robert F. McCarron, M.D. * J.Tod Ghormley, M.D. * Thomas S. Roberts, M.D. * Benjamin M. Dodge, M.D. * H. Scott Smith, M.D. * James T. Howell, M.D.* Grant W. Bennett, M.D. * Glenn McClendon, D.P.M. * 550 Club Lane, Suite 1, Conway, AR I (patient), hereby consent to allow the following persons access to information on my account that would otherwise be considered Protected Health Inormation. (Such as: A Spouse, Friend, Siblings, Children, etc.) Signature of Patient or Parent/Guardian TEL: FAX: TOLL FREE:

4 Account # : AUTHORIZATION FOR PAYMENT OF BENEFITS I request that payment of authorized Medicare benefits, if applicable, be made on my behalf to Conway Orthopedic and Sports Medicine Clinic, PA (COSMC) service furnished to me by that provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I hereby authorize COSMC to release to any third party carrier all records and other information acquired in the course of my examination or treatment pertinent to collecting this account. I understand that I am financially responsible for any charge that are not covered by my insurance company or that have been denied by my insurance company (or) companies. I also understand that I am financially responsible in the event workman's compensation has denied coverage. I permit a copy of this authorized signature to be used in place of the original for medical records to be released. I hereby authorize COSMC to treat the patient indicated. Signature FINANCIAL POLICY It is the intention of all members of our office to provide the best medical care possible in the most efficient manner. Therefore, we wish to make you, the patient, aware of the financial procedures followed by our office. If at any time you have questions regarding any treatment, fee or service, please discuss them with us promptly and frankly. We will make every effort to avoid any misunderstandings. A statement of charges and payments will be sent to you only after your insurance company has addressed them and not before. Regardless of your medical insurance coverage, our clinic relies on you for settling your account. You are ultimately responsible for all clinic and/or surgery charges related to your care. Your health insurance policy is an agreement between you and your health insurance carrier. We participate in a variety of health care insurance programs, which aid in the payment of medical costs. Should there be a problem with any insurance claim, we suggest that you first direct your questions to your insurance carrier. Our insurance department will be pleased to assist you in any way we can. Furthermore, patients must realize that the professional services are rendered to a person, not an insurance company. Therefore, the insurance company is responsible to the patient, and the patient is responsible to us. Many changes have occurred in the health care industry recently, procedures and services that were once covered are either only partially covered, or in some instances, they are not covered at all. If you have been injured in a motor vehicle accident, we will not file the third part's insurance, we will however file our own car insurance or private health insurance. If you do not have either of these we will make payment arrangements. In cases that attorneys are involved, we do not bill the attorney and/or wait for settlement. We look to the patient as the responsible party in all cases. Surgical fees will be billed to your insurance carrier f your insurance information is provide to our office prior to surgery. It is your responsibility to pay any deductible amount, co-insurance, and/or other balances left unpaid by your insurance company. Your physician's bill is separate from any hospital charges you may incur. You may also get bills from the surgery center and/or anesthesia is applicable. Please contact their offices with questions regarding their bills. All paperwork or forms that need to be completed by our physicians must be given to the receptionist. There is a fee for completion of certain types of paperwork. Our insurance department will be happy to assist you with utilizing Visa, MasterCard and Discover services or any other financial arrangements that may be necessary. Patient's Name: (please print) Signature: Revised 3/10

5 Account # : Conway Orthopaedic & Sports Medicine Clinic 550 Club Lane, Suite 1 Conway, Arkansas NOTICE OF PRIVACY PRACTICES: Acknowledgement of Receipt By signing this form, you acknowledge receipt of the Notice of Privacy Practices of Conway Orthopedic and Sports Medicine Clinic, PA. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting our clinic at If you have any questions about our Notice of Privacy Practices, please contact our Privacy Official at I acknowledge receipt of the Notice of Privacy Practices of Conway Orthopaedics & Sports Medicine Clinic, PA. Signature (Patient or Patient Representative) ****TO BE COMPLETED IF PATIENT IS UNABLE TO SIGN FOR THEMSELVES**** It is not possible to obtain the individual's acknowledgement, describe the good faith efforts made to obtain the individual's acknowledgement, and the reasons why the acknowledgement was not obtained. Signature of Patient Representative Revised 3/10

6 Account # : 1 of 2 NAME: DATE: PHARMACY: Medications: Please list all medications you are taking (prescription or over the counter). Allergies: Please list all drug allergies. Social History: Please check box that applies: Smoking Status: Do you drink alcoholic beverages: Marital Status: [ ] Never [ ] Never [ ] Married [ ] Every day smoker [ ] Occasionally [ ] Divorced [ ] Some day smoker [ ] Moderately [ ] Widowed [ ] Former smoker [ ] Formerly [ ] Single [ ] Heavy tobacco smoker Do you have children: [ ] Significant Other [ ] Light tobacco smoker [ ] Yes Height: For how long?: [ ] No Weight Employment: [ ] Part time [ ] Retired [ ] Student [ ] Disabled [ ] Full time [ ] Unemployed [ ] Self Employed Family History: Check box if any of your blood relatives ever had any of the following diseases: Medical Condition Parents Grandparents Siblings Other ( Please specify ) Aneurysm Arthritis Cancer (type) Dementia Diabetes Gout Heart Attack Heart Disease High Blood Pressure Renal Failure Rheumatoiod Arthritis Stroke Thyroid Revised 2/14

7 Account # : 2 of 2 NAME: DATE: Illnesses/Medical Condition: Such as high blood pressure, hepatitis, diabetes, etc: Past Surgical History: Please list any surgeries major/minor that you have had in the past (include right or left). Review of Systems: Please check box if you are experiencing any of the items below: [ ] Abdominal pain [ ] Falling [ ] Shortness of breath [ ] Abnormal masses/bumps [ ] Fever [ ] Sinus problems [ ] Anxiety/panic attacks [ ] Hallucinations [ ] Skin rash [ ] Blood in stool [ ] Headache [ ] Skin ulcers [ ] Blood in urine [ ] Hearing problems [ ] Stomach problems/ulcers [ ] Chest pain or discomfort [ ] Heart palpitations [ ] Swallowing problems [ ] Constipation [ ] Heartburn/Reflux [ ] Swelling in legs [ ] Coughing [ ] Hoarse voice [ ] Visual problems [ ] Depression [ ] Insomnia [ ] Weakness / Numbness in Limbs [ ] Diarrhea [ ] Memory loss [ ] Weight gain/loss (past year) [ ] Difficulty with urination [ ] Nausea/vomiting [ ] Wheezing [ ] Dizziness/Fainting [ ] Seizures Primary Care Physician: Referring Physician: Additional Information (optional): Religious Preference: Home Church: Pastor/Priest's Name (optional): Are You Right/Left Handed: Using birth control pills?: History of sexually transmitted disease: Drugs (pot, cocaine, speed/methamphetamines): Do you have an increased chance of having AIDS?: Revised 2/14

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