NEW PATIENT REGISTRATION FORM

Transcription

1 NEW PATIENT REGISTRATION FORM Legal Name: Home Address: Last First Middle Preferred Street Apt# City/ST/Zip Phone(s): Home: Cell: Work: DOB: Age: DL#: Gender: M or F Marital Status: Single Married Divorced Widow SS# Employer Name: Employer Phone#: Employer Address: Occupation: Street City/ST/Zip How did you hear about us? Primary Care Doctor: Doctor Phone#: PRIMARY INSURANCE INFORMATION: ( FILL IN INSURANCE INFORMATION BELOW OR CHECK BOX IF COPY OF CARD WAS PROVIDED) Name of Primary Policy Holder: As It Appears On Card Relationship to Patient: DOB: Insurance Company: Insurance Phone#: Policy ID#: Group#: MEDICARE SUPPLEMENTAL INSURANCE INFORMATION: Name of Primary Policy Holder: As It Appears On Card Policy ID/Group#:_ RESPONSIBLE PARTY INFORMATION: ( Name: CHECK IF SAME AS ABOVE) Address: DOB: SS#: Phone#:_ Relationship to Patient: EMERGENCY CONTACT/LEGAL GUARDIAN: Name: Phone#: Relationship to Patient: RELEASE OF INFORMATION AND ASSIGNMENTS OF BENEFITS: I hereby authorize the above-named agency to release my treatment information requested by attorneys, physicians, insurance companies, employers, healthcare providers or any other entity which may be concerned with the payment of charges incurred for the treatment of services of Plano Orthopedic Sports Medicine & Spine Center, P.A., and hereby authorize payment directly to Plano Orthopedic Sports Medicine & Spine Center, P.A. for services rendered. I accept responsibility for payment of any charges not paid for or accepted by my insurance. This authorization remains valid and effective from the date of signing until revoked in writing. Signature of Patient or Legal Guardian Date

2 Clinic Financial, HIPAA & Privacy Policies, Consent to Treat PLEASE INITIAL ALL SECTIONS, SIGN & DATE FORM FINANCIAL RESPONSIBILITY AGREEMENT: I agree to assign insurance benefits to Plano Orthopedic Sports Medicine & Spine Center, P.A. We bill all insurance companies that we are contracted with as network providers as a courtesy to our patients. I acknowledge full financial responsibility for services rendered by Plano Orthopedic Sports Medicine & Spine Center, P.A. and authorize transfer of all unpaid amounts to me, which includes, but is not limited to, Co-pays, Deductibles, Co-Insurance, Preexisting Clauses, excluded conditions and/or termination of coverage. I agree to pay all legal fees including a ttorney and court fees as well as collection costs in the event of default payment of charges that are my financial responsibility. I further autho rize and request all insurance payments be made directly to Plano Orthopedic Sports Medicine & Spine Center, P.A. PATIENT PRIVACY PRACTICES: We are committed to ensuring your Protected Health Information (PHI) remains confidential. Your paper and electronic medical records are safeguarded and released only with your consent or to your insurance carrier, other medical professionals directly involved with your care, or as required by law. Our Notice of Privacy Practices policy manual, which explains how your medical information may be used and disclosed, is available for your review or you are welcome to have a copy. If you would like to release your PHI to another doctor or facility you will be required to fill out a separate form to request your records. HIPAA & RELEASE OF INFORMATON: I hereby authorize Plano Orthopedics Sports Medicine & Spine Center, P.A. to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment and other health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Plano Orthopedics Sports Medicine & Spine Center, P.A. can refuse to see me. I have been provided with access to either review and/or receive a copy of Notice of Privacy Practices for Plano Orthopedic Sports Medicine & Spine Center, P.A. which more fully describes the uses and disclosures, and I understand that I have the right to review such notice prior to signing this consent. I understand I can revoke this consent at any time by notifying Plano Orthopedics Sports Medicine & Spine Center, P.A. in writing. I understand Plano Orthopedics Sports Medicine & Spine Center, P.A. has the right to change its privacy policies and that I can receive such changed notices upon r equest. I understand that I have the right to request that Plano Orthopedics Sports Medicine & Spine Center, P.A. restrict how my individually identifiable health information is used and/or disclosed to carry out treatment, payment, or other healthcare operations. I understand that Plano Orthopedics Sports Medicine & Spine Center, P.A. does not have to agree to such restrictions, but that once such restrictions are agreed to, Plano Orthopedics Sports Medicine & Spine Center, P.A. must adhere to such restrictions. RELEASE OF MEDICAL INFORMATION AUTHORIZATION: I give Plano Orthopedics Sports Medicine & Spine Center, P.A. authorization for the release of Medical Records/Privacy Infor mation, which includes your PHI, any medical conditions and/or billing and financial information to the following: Name: Relationship to Patient: _ CONSENT OF TREATMENT: I authorize Plano Orthopedics Sports Medicine & Spine Center, P.A. Physicians and the Physician s Assistants to evaluate and treat me or my family member for any orthopedic illness or injury for which I seek medical care. I have read and understand the above clinic polices and I further acknowledge that I accept the terms outlined in each of the above policies. MEDICATION POLICY CONSENT: I authorize Plano Orthopedics Sports Medicine & Spine Center, P.A. Physicians and the Physician s Assistants to obtain a medication history and/or list of current medications via my pharmacy for medical records.

3 PA-C CONSENT, POSMC DISCLOSURE PHYSICIAN ASSISTANT CONSENT This facility has on staff Certified Physician Assistants (PA-C) to assist in the delivery of orthopedic medical care. I acknowledge a Physician Assistant is not a physician. A PA-C is licensed by the state medical board and under the supervision of a physician can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. Supervision does NOT require constant physical presence of the supervising physician, but rather overseeing and accepting responsibility for t he medical services provided. A list of services may be provided that are within the scope of practice for a PA-C upon request. I hereby acknowledge the above information and consent to the services of a Certified Physician Assistant for my health care ne eds. I understand that at any given time I can request to see the Physician instead of the PA-C. DISCLOSURE OF FINANCIAL INTEREST Plano Orthopedic Sports Medicine & Spine Center, P.A. physician you are seeing may have a financial inter est in the facilities listed below. The facilities and our physicians are committed to providing clinical excellence in a safe and attractive environment for you and your family members. Their financial interest in these facilities enables them to have a voice in administration and the ir policies. This involvement helps to ensure the highest quality of care for you. Should you have any concerns regarding this notice, please ask your physician or a member of the staff. My initials above verify that I have read and understand the above statement and information. Baylor Medical Center at Frisco Plano Therapy Center 5601 Warren Pkwy 3405 Midway Ste 500 Frisco, TX Plano, TX Texas Health Center for Diagnostic & Surgery 6020 W Parker Rd Plano, TX Methodist Hospital for Surgery N Dallas Pkwy Addison, TX Surgery Center of Plano 1620 Coit Road Plano, TX Preston Plaza Surgery Center Preston Rd Ste 75 Dallas, TX Allen Therapy Center 1223 W McDermott Ste 50 Allen, TX North Star MRI (Frisco) 8501 Wade Blvd Ste 220 Frisco, TX North Star MRI (Plano) 3700 W 15 th St Bldg D Ste 200 Plano, TX North Star MRI (Allen) 997 Raintree Circle Ste 110 Allen, TX Baylor SurgiCare North Garland 7150 N. President George Bush Hwy Garland, TX (214) Dr. Stephen Courtney, a POSMC physician also has a financial interest in Eminent Spine, a company that manufactures and designs spinal implants. Eminent Spine & Eminent Extremity 7200 N. IH 35 Bldg #1 Georgetown, TX Dr. John E. McGarry, a POSMC physician also has a financial interest in T5 Ortho, a company that distributes medical products. ACKNOWLEDGEMENT: I acknowledge that I received access to the Notice of Privacy Practices information for Plano Orthopedics Sport Medicine & Spine Center, P.A. I have read and understand the HIPAA & Release of Medical Information Policy. I hereby authorize Plano Orthopedic Sports Medicine & Spine Center, P.A. to release any information requested by the insurance company or companies or respective representatives and act as my agent to secure payment from any and all services rendered. I understand that I am financially responsible to the physician for any and all charges incurred by myself and/or dependents. I have read and understand the Physician s Consent and the Disclosure of Financial Interest I further acknowledge and understand that I accept the terms outlined in each of the policies. X Patient or Guardian Signature Date

4 UNIVERSAL CONDITION, INJURY/ACCIDENT STATEMENT FORM ALL BOXES MUST BE COMPLETED BEFORE SEEING A PHYSICIAN PATIENT NAME: TODAY S DATE: / / PLEASE COMPLETE THE FOLLOWING STATEMENTS. MOST INSURANCE COMPANIES REQUEST ACCIDENT DETAILS. THIS INFORMATION MAY BE FORWARDED WITH YOUR INSURANCE CLAIM OR PROVIDED TO AN ADJUSTER TO COMPLETE YOUR CLAIM. WE MUST HAVE BOX 1: CONDITION OR DATE OF INJURY COMPLETED TO FILE YOUR CLAIM. 1. Please check: CONDITION INJURY INJURY DATE: / / (ON OR ABOUT) How did the injury or pain occur, what were you doing? (Brief Summary) THIS DATE IS REQUIRED FOR INSURANCE FILING 2. Did the injury occur during work? YES NO 3. Were you clocked in? YES NO 4. Were you at lunch? YES NO THIRD PARTY LIABILITY 5. Is there a possible third party liability? YES NO (INJURY OCCURRED SOMEWHERE OTHER THAN HOME OR WORK? SUCH AS AUTO, HOMEOWNER S PROPERTY, ETC.?) IF YES, A letter of subrogation should be provided before seeing the physician. Your health insurance will deny the claim if the letter is not obtained. I certify that this information to be true and accurate. I hereby authorize the release of a copy of this form as may be nec essary to obtain reimbursement from any insurance company which may request information regarding my injury or condition and the na ture of my treatment. I also understand that I am responsible for responding promptly to my insurance carrier if they request any ad ditional information, and that failure to provide requested information may categorize my treatment as a non-covered service and may make me personally liable for the charges incurred. SIGNATURE: TODAY S DATE: / / (RESPONSIBLE PARTY)

5 Patient Name: Height: Weight: Race: African American Asian Caucasian Native American/Alaskan Pacific Islander Other Unknown Decline to Answer Ethnicity: Hispanic Non-Hispanic Unknown Decline to Answer Preferred Language: English Spanish Chinese Other Preferred Pharmacy: Pharmacy Phone Referral Source: Doctor (name): Chief Complaint Dominant Hand: Right Left Ambidextrous Other (ex. Google search): Description of Symptoms: (select only ONE primary symptom) Pain Numbness/Tingling Fracture Stiffness Other: Shoulder Right Left Pelvis Right Left Neck Upper Arm Right Left Hip Right Left Upper Back Elbow Right Left Thigh Right Left Mid Back Forearm Right Left Knee Right Left Low Back Wrist Right Left Lower Leg Right Left Buttocks Hand Right Left Ankle Right Left Tail Bone Thumb Right Left Foot Right Left Index Right Left Great Toe Right Left Middle Right Left 2nd Digit Right Left Ring Right Left 3rd Digit Right Left Little Right Left 4th Digit Right Left 5th Digit Right Left Pain radiates from/to: (ex. from low back to right leg) History of Present Illness 1. Is your problem the result of an injury or accident? No Injury Injury Injury at Work Auto Accident Sport Injury Prior Surgery How long have the symptoms been present? (ex. 2 days, 4 months) Describe the onset: Acute (sudden) Chronic condition (>3 months) Onset Date: (mm/dd/yyyy) 2. Are you represented by an attorney? Yes No Attorney Name: Will there be any legal actions with respect to this problem? Yes No 3. Have you had a problem like this before? Yes No Describe: 4. Have you been seen in an ER for this problem? Yes No Treating ER: Date: (mm/dd/yyyy)

6 Page 2 Patient Name: History of Present Illness (continued) 5. Rate the pain (10 being the most pain): Do the symptoms wake you from sleep? Yes No 7. Please describe the symptoms: Sharp Dull Stabbing Throbbing Aching Burning Shooting 8. What is the timing of the symptoms? Constant Intermittent (comes and goes) 9. Is the problem getting better or worse? Getting better Getting worse Unchanged 10. What makes the symptoms worse? Squatting Kneeling Sitting Bending Stairs Twisting Moving Lying in bed Running Walking Athletics Standing Gripping Lifting Reaching Overhead 11. Are there any other symptoms associated with this problem? Redness Bruising Swelling Numbness Stiffness Limping Clicking Locking Popping Tingling Weakness Giving way Prior Testing / Treatment Have you had any prior tests for this problem? None X-rays MRI CT Scan Nerve Test (EMG/NCV) Bone Scan Have you had any prior treatment for this problem? Yes No Type of treatment Status of symptoms after treatment (select only those that apply) Date of treatment Ice Improved Worsened Unchanged Heat Improved Worsened Unchanged Rest Improved Worsened Unchanged NSAIDs Improved Worsened Unchanged Muscle Relaxers Improved Worsened Unchanged Chiropractor Improved Worsened Unchanged Physical Therapy Improved Worsened Unchanged HomeExerciseProgram Improved Worsened Unchanged Surgery Improved Worsened Unchanged Injections Improved Worsened Unchanged Bracing Improved Worsened Unchanged TENS unit Improved Worsened Unchanged Other/Comments:

7 Page 3 Patient Name: Select all previous hospitalizations/surgeries: None Aneurysm (Brain) Surgery Hysterectomy Orthopedic on side: Right Left Aortic Bypass / Vascular Surgery LAP Band / Gastric Bypass Arthroscopy: Knee Appendectomy Lumpectomy Arthroscopy: Shoulder Cataract (Eye) Surgery Mastectomy Carpal Tunnel Release Cholecystectomy (Gallbladder) Malignancy/Cancer Rotator Cuff Repair Heart Surgery Stents Total Hip Replacement Hernia Repair Total Knee Replacement Total Shoulder Replacement Spinal Surgery - Indicate Level: Other Surgery Other Orthopedic Surgery Medical Questions Mark all that currently apply: Metal in body Claustrophobic Pregnant Sleep Apnea Uses a CPAP Snores Are you taking blood thinners? Yes No Review of Systems Please indicate if you have experienced any of the following symptoms in the last 6 months? None 1) GI Heartburn, Ulcers Nausea, Vomiting Blood in Stool 2) ENDO Fever Heat or Cold Intolerance Night Sweats 3) CON Weight Loss Loss of Appetite Fatigue 4) EYE Blurred Vision Double Vision Vision Loss 5) ENT Hearing Loss Hoarseness Trouble Swallowing 6) CV Chest Pain Palpitations Comments 7) RS Chronic Cough Pneumonia Shortness of Breath 8) GU Painful Urination Blood in Urine Kidney Problems 9) SK Frequent Rashes Skin Ulcers Lumps Psoriasis 10) NEU Frequent Falls Loss of Coordination Numbness Change in Bowel Change in Bladder Dizziness 11) PSY Depression/Anxiety Drug/Alcohol Addiction Sleep Disorder 12) HEM Easy Bleeding Easy Bruising Anemia

8 Page 4 Patient Name: Family History Have any direct relatives had any of the following disorders? Father None Diabetes Heart Disease Hypertension Social History Do you use tobacco? Current, every day Current, some day Former tobacco use Never Do you drink alcohol? Daily Occasionally Rarely Never Marital Status: Married Single Divorced Widowed Domestic Partnership Are you currently working? Yes No Retired Disabled If no, what date did you last work? Please list work restrictions, if any: Occupation: Employer: Student Pain Diagram Bleeding Problems Epilepsy Connective Tissue Muscular Dystrophy Stroke Osteoporosis Rheumatoid Arthritis Cancer Comments (ex. cancer type) Mother None Diabetes Heart Disease Hypertension Bleeding Problems Epilepsy Connective Tissue Muscular Dystrophy Stroke Osteoporosis Rheumatoid Arthritis Cancer Comments (ex. cancer type) Sibling None Diabetes Heart Disease Hypertension Bleeding Problems Epilepsy Connective Tissue Muscular Dystrophy Stroke Osteoporosis Rheumatoid Arthritis Cancer Comments (ex. cancer type)

9 Page 5 Patient Name: Do you have any allergies? Yes No If Yes, please list below: Medication, Relevant Food Reaction Latex allergy? Yes No Please list all medications you take on a regular basis: None Medication Dosage and Frequency (e.g. 20 mg, once/day) Do you have a personal history of any of the following? None Aneurysm Where: Emphysema Kidney Disease Angina (Chest Pain) Epilepsy Kidney Stones Arthritis Type: Heart Attack MRSA Infection Asthma Hepatitis Type: Pacemaker Bone or Joint Infections HIV / AIDS Phlebitis (Blood Clots) Cancer Type: High Cholesterol Pulmonary Embolism Chemotherapy / Radiation Hypertension Reaction to Anesthesia Type: COPD Hyperthyroidism Seizures Congestive Heart Failure Hypothyroidism Stomach Ulcers Diabetes Type: Last A1C: Stroke / TIA Tuberculosis Please list any other conditions or details of conditions marked above: Signature Date