AUTO LIABILITY Please Print: Name (First): (MI): (Last): Date: Address: City: State: Zip: Home Phone: Cell Phone:

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1 HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine CLIVE C. WOODS, MD Orthopaedic Surgeon Fellowship Trained in Foot and Ankle Surgery AUTO LIABILITY Please Print: Name (First): (MI): (Last): Date: Address: City: State: Zip: Home Phone: Cell Phone: Driver s License #: Driver s License State: Occupation: DOB: Age: Sex: SSN#: Employer/School: Business Phone#: Address: If patient is a minor- Please complete: Father s Name: Mother s Name: Employer: Employer: Position: Phone: Position: Phone: Please list the name of a person to contact in case of an emergency other than a spouse or parent: Name: Relationship: Phone: Address: City: State: Zip: Do you have an attorney? Yes No If yes, Name: Phone#: Address: AUTO INSURANCE- Please have Insurance cards ready to be copied Name of Company: Phone: Address: City: State: Zip: Insured s Full Name: Insured s SS#: Insured s DOB: Policy#: Claim#: PRIMARY INSURANCE-Please have Insurance cards ready to be copied Name of Company: Phone: Address: City: State: Zip: Insured s Full Name: Is this an Employer s Plan Yes No Insured s SS#: ID#: Group# Insured s DOB: Relationship to insured: (self, spouse, child, other): AUTHORIZATION FOR TREATMENT/RELEASE OF INFORMATION/FINANCIAL AGREEMENT: I give permission to administer treatment and perform tests as determined necessary by the physician in the diagnosis and treatment of my condition. Furthermore, I authorize the release of information relating to my medical treatment to my insurance company in order to process my claim services. I request that payments for insurance benefits made on my behalf, be paid directly to Howard J. Gelb, MD,PA. I assume full financial responsibility for all bills associated with this office and all tests, treatments, x-rays etc., that are not covered by my insurance. Payment is expected at the time of service, including all applicable co-payments and deductibles. I further understand that it is my responsibility to get authorization from my Primary Care Physician or Insurance Company (if required by the insurance company) prior to services being rendered. I understand that no guarantee or assurance has been made as to the results of the procedure or treatment and that it may not cure the condition. Should this become a collection problem, (the patient/client/debtor) assumes all costs of collection, including, but not limited to court costs, interest and legal fees. Patient s or Legal Guardian s Signature Date: Howard J. Gelb, MD, PA 9980 Central Park Blvd N., Suite 222 Boca Raton, FL P: F:

2 HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine CLIVE C. WOODS, MD Orthopaedic Surgeon Fellowship Trained in Foot and Ankle Surgery Please Print: LIABILITY PATIENT INFORMATION Name (First) (Last) Date: Age: Ht: Wt: Male Female Right Handed Left Handed Ambidextrous Occupation: How were you referred to our office? Who is your Primary Physician Phone #: HISTORY OF PRESENT ILLNESS Describe the condition that brought you to this office: Is your injury: Work Accident Auto Accident Slip & Fall Date when Accident/Injury occurred: Where did Accident/Injury Occur? Description of Accident/Injury: If this is an auto accident, were you thrown from the car? Yes No Did you lose consciousness? Yes No Contributing events or cause for symptoms: Describe the severity and quality of pain: (sharp, dull, stabbing, etc.) Circle rating of 1-10 for severity of symptoms with 10 being the greatest: Frequency of symptoms: Constant Intermittent Daily Duration of symptoms: Constant Hrs Mins Seconds Do symptoms include? Swelling Weakness Numbness Decreased Motion Pins & Needle Sensation Other If applicable, is the joint? Popping Locking Clicking Instability/Giving way Other What activities worsen your condition? When do the symptoms occur? Morning Afternoon Evening During Exercise After Exercise Have you been previously treated for this accident/injury elsewhere? If yes, by whom? Past Treatment of your current problem: Ice treatment Heat Treatment Physical Therapy Rest (Length of Time) Injections (How Many?) Medications Related Past Surgeries for condition (Specify Procedure & Date) Howard J. Gelb, MD, PA 9980 Central Park Blvd N., Suite 222 Boca Raton, FL P: F:

3 TODAYS DATE WHICH PHYSICIAN ARE YOU SEEING TODAY? NAME (LAST) (FIRST) (MI) ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE WORK PHONE MALE FEMALE DATE OF BIRTH SOCIAL SECURITY # DRIVERS LICENSE # DRIVERS LICENSE STATE LOCAL PHARMACY NAME PHARMACY PHONE OCCUPATION: IN CASE OF AN EMERGENCY PLEASE CONTACT NAME RELATIONSHIP PHONE ADDRESS CITY STATE ZIP PRIMARY INSURANCE - Please have Insurance cards ready to be copied PRIMARY INSURANCE CARRIER PHONE POLICY # GROUP # INSURED DOB INSURED SS# ADDRESS CITY STATE ZIP SECONDARY INSURANCE SECONDARY INSURANCE CARRIER PHONE POLICY # GROUP # INSURED DOB INSURED SS# ADDRESS CITY STATE ZIP IF THE PATIENT IS A MINOR (UNDER AGE 18) - PLEASE COMPLETE: FATHER S NAME EMPLOYER/POSITION PHONE MOTHER S NAME EMPLOYER/POSITION PHONE AUTHORIZATION FOR TREATMENT/RELEASEOF INFORMATION/FINANCIAL AGREEEMENT: I give permission to administer treatment and perform tests as determined by the physician in the diagnosis and treatment of my condition. Furthermore, I authorize the release of information relating to my medical treatment to my insurance company in order to process my claim services. I request that payments for insurance benefits made on my behalf, be paid directly to Howard J. Gelb, MD PA. I assume full financial responsibility for all bills associated with this office and all tests, treatments, x- rays, etc. that are not covered by my insurance. Payment is expected at the time of service, including all applicable co- payments and deductibles. I further understand that it is my responsibility to get authorization from my Primary Care Physician or Insurance Company (if required by the insurance company) prior to services being rendered. I understand that no guarantee or assurance has been made as to the results of the procedure or treatment and that it may not cure the condition. Should this become a collection problem the patient assumes all costs of coaction, including, but not limited to court costs, interest and legal fees. Patient s or Legal Guardian s Signature: Date:

4 NAME: DATE: PLEASE CHECK ONE: ETHNICITY: HISPANIC/LATINO NON HISPANIC/NONLATINO OTHER RACE: AMERICAN INDIAN ASIAN BLACK/AFRICAN AMERICAN NATIVE HAWAIIAN WHITE OTHER PRIMARY LANGUAGE: ENGLISH SPANISH FRENCH ITALIAN GERMAN PORTUGUESE JAPANESE CHINESE RUSSIAN OTHER MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOW I WAS REFERRED TO THIS OFFICE BY (PLEASE CHECK ONE): ANOTHER PHYSICIAN: (DR. ) ATTORNEY PHYSICALTHERAPIST OTHER IS YOUR INJURY: WORK ACCIDENT AUTO ACCIDENT SLIP & FALL(LEGAL CASE) SPORTS REALTED OTHER INJURY *PLEASE SPECIFY RIGHT OR LEFT SIDE AND BODY PART OF CONDITION AND BRIEFLY DESCRIBE WHAT BROUGHT YOU INTO THIS OFFICE. PLEASE INCLUDE DATE OF INJURY, HOW, WHEN AND WHERE OCCURRED: DID YOU BRING ANY X- RAYS, MRIs, CDs, DVDs, FILMS? Yes No IF YES, PLEASE SUPPLY TO OUR STAFF. REVIEW OF SYSTEMS CONSTITUTIONAL CHILLS FATIGUE FEVER WEIGHT GAIN WEIGHT LOSS INTEGUMENTARY SKIN LESIONS RASH REDNESSS OF SKIN MOLES DRY OR SCALY SKIN EYES,EARS,NOSE,THROAT BLURRRED VISION CATARACTS CONTACT LENS GLAUCOMA HEARING LOSS DRY MOUTH NASAL CONGESTION SORE THROAT TINNITUS LOOSE TEETH RESPIRATORY COUGH DIFFICULTY BREATHING WHEEZING ASTHMA EMPHYSEMA BREATHING TREATMENT CARDIOVASCULAR CHEST PAIN CHORTNESS OF BREATH DYSPNEA ON EXERTION ANGINA PALPITATIONS INTERMITTENT PAIN IN LEGS SWELLING/EDEMA GASTROINTESTINAL DIARRHEA BLOODY STOOL NAUSEA VOMITING ULCERS FOOD INTOLERANCE GENITOURINARY BURNING ON URINATION BLOODY URINE DIFFICULTY VOIDING HISTORY OF UTI NEUROLOGICAL NUMBNESS SEIZURES BALANCE PROBLEMS TINGLING DIZZINESS DIFFICULTY WALKING FREQUENT URINATION PSYCHIATRIC DEPRESSION ANXIETY INSOMNIA ADDICTION DRUG USE HISTORY OF PSYCHIATRIC PROBLEMS HEMATOLOGY ABNORMAL BLEEDING BLOOD CLOTS AIDS CANCER SITE MUSCULOSKELETAL (PLEASE SPECIFY RIGHT OR LEFT) BACK PAIN DECREASED RANGE OF MOTION JOINT PAIN JOINT STIFFNESS SWELLING NECK PAIN ARM PAIN [ R or L] SHOULDER PAIN [ R or L] HIP PAIN [ R or L] KNEE PAIN [ R or L] ANKLE PAIN [ R or L] FOOT PAIN [ R or L] HEEL PAIN [ R or L] WRIST PAIN [ R or L] ELBOW PAIN [ R or L] HAND PAIN [ R or L] LOCKING GIVING WAY PARTIAL GIVING WAY PAIN WITH MOTION TYPE ENDOCRINE THIRST FREQUENT URINATION NIGHT SWEATS

5 NAME: DATE: HISTORY MEDICAL (CHECK ALL THAT APPLY): ASTHMA ARTHRITIS ANEMIA ANXIETY BLOOD CLOTTING TENDENCY CATARACTS COPD DEPRESSION DIABETES I / II DRUG DEPENDENCY EPILEPSY EMPHYSEMA GOUT HEADACHE HEART DISEASE HIGH BLOOD PRESSURE KIDNEY DISEASE LIVER DISEASE PEPTIC ULCER PSORIASIS VISION LOSS CANCER TYPE HEPATITIS TYPE OTHER ALLERGIES TO MEDICATIONS (CHECK ALL THAT APPLY): ASPIRIN CODEINE IODINE NOVACAINE PENICILLIN TAPE OR ADHESIVES SULFA OTHER NO KNOWN ALLERGIES ARE YOU: RIGHT HANDED LEFT HANDED AMBIDREXTROUS SMOKING HISTORY: NEVER PREVIOUSLY,BUT QUIT CURRENT SMOKER: PACKS PER DAY ALCOHOL USE: NONE RARE SOCIALLY OCCASIONALLY OTHER PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING INCLUDING DOSAGE::,,,,,, PAST SURGERY APPENDECTOMY ARTHROSCOPY BACK SURGERY BREAST SURGERY CARPAL TUNNEL GALLBLADDER HEART BYPASS HEART VALVE REPLACEMENT HERNIA REPAIR HYSTERECTOMY JOINT REPLACEMENT NECK SURGERY PACEMAKER PROSTATE SURGERY TONSILECTOMY OTHER HEIGHT FT IN WEIGHT LBS SHOE SIZE LIST PARTICIPATING SPORTING ACTIVITIES: FAMILY HISTORY FATHER: ALIVE? YES NO AGE: MEDICAL CONDITIONS: MOTHER: ALIVE? YES NO AGE: MEDICAL CONDITIONS: SIBLINGS: ALIVE? YES NO AGE: MEDICAL CONDITIONS:

6 HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine CLIVE C. WOODS, MD Orthopaedic Surgeon Fellowship Trained in Foot and Ankle Surgery PATIENT CONSENT FORM The Department of Health and Human Services has established a Privacy Rule to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment payment of health care operations, in order to provide health care that is in your best interest. We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information, (PHI).If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objection to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restriction and revoke consent in writing after you have reviewed our privacy notice. Printed Name: Signature: Date: Howard J. Gelb, MD, PA 9980 Central Park Blvd N., Suite 222 Boca Raton, FL P: F:

7 HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine CLIVE C. WOODS, MD Orthopaedic Surgeon Fellowship Trained in Foot and Ankle Surgery Please check all appropriate boxes: I, give permission to Howard J. Gelb, MD, Clive C. Woods, MD, (Patient s name) or his staff to leave any test results or exam results: Leave message on answering machine or fax at home Leave message with spouse or family member Leave message with (name of person) Leave message on voice mail at work Leave message with only myself by phone or fax I, give permission for my medical records to be faxed or (Patient s name) mailed upon request to: My Primary physician Any other physician or facility that will be involved with my care Dr. Howard Gelb My insurance carrier I, give permission to Dr. Gelb or Dr. Woods to discuss my medical (Patient s name) condition with: My spouse My children My parents Other I hereby authorize the release of any medical records necessary for Dr. Gelb or Dr. Woods to render medical services by signing a lifetime signature below: Signature Date Howard J. Gelb, MD, PA 9980 Central Park Blvd N., Suite 222 Boca Raton, FL P: F:

8 HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine CLIVE C. WOODS, MD Orthopaedic Surgeon Fellowship Trained in Foot and Ankle Surgery LIABILITY STATEMENT According to the information given to Dr. Gelb/Dr. Woods, I am being treated as a patient who was involved in an auto accident for which I am holding another party liable for my injury. I agree to supply the proper billing information necessary to cover any charges that are incurred during my treatment with Dr. Gelb/Dr. Woods. However, I have been informed that regardless of insurance payments or settlements. I am fully responsible for any balance not paid or covered by insurance or other parties involved. I understand that the auto carrier and/or insurance company that I am seeking payment from may not cover the entire bill. The standard reimbursement from an auto insurance carrier is 80% with benefit limitations under PIP. Re-imbursement rates from other carriers cannot be determined or guaranteed. Private health insurance companies and Medicare WILL NOT pay for non-covered amounts, therefore Dr. Gelb/Dr. Woods WILL NOT BILL THEM FOR co-ordination of benefits. I fully agree to pay any remaining balances to Howard J. Gelb, MD, PA within 90 days. I realize that Dr.Gelb/Dr.Woods, do not accept payment from my insurance company as payment in full and does not wait for litigation settlements for the balance of my bill. I,, agree to the terms explained above. In addition, I understand that my account may be placed with a collection agency for any unpaid balances over 90 days. I will be responsible for any additional costs/fees for this process. PATIENT SIGNATURE DATE SIGNED Howard J. Gelb, MD, PA 9980 Central Park Blvd N., Suite 222 Boca Raton, FL P: F:

9 HOWARD J. GELB, M.D., F.A.A.O.S. Board Certified Orthopaedic Surgeon Fellowship Trained in Sports Medicine Sub-specialty Certified in Sports Medicine CLIVE C. WOODS, MD Orthopaedic Surgeon Fellowship Trained in Foot and Ankle Surgery INTENT TO TREAT LETTER Auto Insurance Company: Policy Number: Claim Number: This letter is to inform you that is starting treatment at the offices of Howard J. Gelb, M.D./Clive C. Woods, M.D., located at 9980 Central Park Blvd North, Suite 222, Boca Raton, FL The patient is being seen for the injury which occurred on / /. If you have any questions regarding this treatment, please notify the billing department at: In accordance with Florida Statute Section (5) (b), the above medical provider has 75 days to submit medical statements. The patient has executed an Assignment of Benefits and Authorization to Release Medical Records on behalf of Howard J. Gelb, M.D. Accordingly, please provide an updated PIP payout ledger to this office every thirty (30) days. Thank you for your anticipated cooperation. Sincerely, Howard J. Gelb, M.D. Clive C. Woods, M.D. Howard J. Gelb, MD, PA 9980 Central Park Blvd N., Suite 222 Boca Raton, FL P: F:

10 ASSIGNMENT OF INSURANCE BENEFITS, POWER OF ATTORNEY AND RELEASE INFORMATION INSURER PLEASE READ THE FOLLOWING, IN ITS ENTIRETY, UPON RECEIPT: I, the undersigned patient/insured knowingly, voluntarily and intentionally assign the rights and benefits of my No-Fault policy of automobile insurance, also known as Personal Injury Protection (P.I.P.), and Medical Payments policy of insurance to the above health care provider, Howard J. Gelb, M.D., P.A. I understand it is the intention of the provider to accept this assignment of benefits in lieu of demanding payment at the time services are rendered and that this document will allow the provider to file against and Insurance company for payment of the insurance benefits. This assignment of benefits includes over due interest payments and any potential claim for common law or statutory bad faith. If the insurer disputes the validity of this assignment of benefits then the Insurer is instructed to notify the provider in writing within five (5) days of receipt of this document. Failure to inform the provider shall result in waiver by the insurer to consent the validity of the document. The undersigned directs the insurer to pay the health care provider directly without including the patient's name on the check. The insurer is directed by the provider and the undersigned to not issue any checks or drafts in partial settlement of a claim the contain or are accompanied by language releasing the insurer or its insured/patient from liability unless there has been prior written settlement agreed to by the health provider and the insurer as to the amount payable under the insurance policy or contract. The provider hereby objects to any reductions or partial payments. Any partial or reduced payment, regardless of the accompanying language, issued by the insurer and deposited by the provider shall be done so under protest, at the risk of the insurer, and the deposit shall not be deemed a waiver, accord, satisfaction, discharge, settlement or agreement by the provider to accept a reduced amount as payment in full. The insurer is hereby placed on notice that this provider reserves the right to seek the full amount of the bills submitted. In the event the subject medical benefits are disputed by the insurer for any reason the undersigned hereby instructs the insurer to set aside any amount disputed (i.e., to escrow the money) and not pay the disputed amount to anyone, including myself, or any entity until the dispute is resolved. The insurer is instructed to immediately explain in writing to the above provider of any dispute. If the insurer schedules a defense examination or examination under oath (herein after 'EUO'0 the insurer is hereby INSTRUCTED to send a copy of said notification to this provider. The provider or the provider's attorney is authorized to appear at any EUO or IME set by the insurer. The health care provider is not the agent of the insurer of the patient for any purpose. This assignment applies to both past and future medical expenses and is valid even if undated. assignment is to be considered as valid as the original. A photocopy of this I agree to pay any applicable deductible, co-payments, for services rendered after the policy of insurance exhausts, and for any other services unrelated to the automobile accident. Power of attorney: The above health care provider is hereby given the power of attorney by the undersigned to sign my name on any checks for payment for services rendered by the above provider. Release of information: I hereby authorize this provider to: furnish the insurer, an insurer's intermediary and the patient's attorney via mail, fax or , with any and all information that may be contained in the medical records; to obtain insurance coverage information in writing (declaration sheet) ad telephonically from the insurer: to request all EOBs and non-redacted PIP payout sheets from the insurer; and to obtain copies of all medical records, including but not limited to, documents, reports, scans, notes, opinions, X-rays, and MRIs, from any other medical provider or any insurer. The insurer is directed to deep the patient's medical records private and confidential. The insurer is NOT authorized to provide these records to anyone, including but not limited to, third party vendors without the patient's and the provider's prior express written permission. I certify that I have not been solicited or promised anything in exchange for receiving health care or that I have received any promises or guarantees from anyone as the results that may be obtained by any treatment. Caution! Please read before signing. If you do not completely understand this document please ask us to explain it to you. If you sign below we will assume you understand and agree to the terms! I hereby accept the above Assignment of Benefits PATIENT'S NAME (PLEASE PRINT) PATIENT'S SIGNATURE DATE (IF PATIENT IS A MINOR, SIGNATURE OF PARENT/GUARDIAN) HOWARD J. GELB, M.D., P.A. DATE

11 OFFICE OF INSURANCE REGULATION Bureau of Property & Casualty Forms and Rates Standard Disclosure and Acknowledgement Form Personal Injury Protection - Initial Treatment or Service Provided The undersigned insured person (or guardian of such person) affirms: 1. The services or treatment set forth below were actually rendered. This means that those services have already been provided. 2. I have the right and the duty to confirm that the services have already been provided. 3. I was not solicited by any person to seek any services from the medical provider of the services described above. 4. The medical provider has explained the services to me for which payment is being claimed. 5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500. Insured Person (patient receiving treatment or services) or Guardian of Insured Person: Name (PRINT or TYPE) Signature Date The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also: A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits. B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent. C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner. D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section (14) and (15), Florida Statutes or Section (5)(b)6, Florida Statutes. Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable (Signature by his/ her own hand): Howard J. Gelb, MD or Clive C. Woods, MD Name (PRINT or TYPE) Signature Date Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree per Section (1)(b), Florida Statutes. Note: The original of this form must be furnished to the insurer pursuant to Section (4)(b), Florida Statutes and may not be electronically furnished. Failure to furnish this form may result in non-payment of the claim. OIR-B Pub. 1/2004

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