MVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms.

Transcription

1 MVA/ PI Registration Form Is this accident work related? YES or No If yes, stop here and notify front desk for different forms. Date: Patient # Patient Name: DOB; Gender: M or F SSN Address: City/State: Zip Home Phone: Work Phone: Cell Phone Emergency Contact: Relationship to patient: Contact phone(s): Patient Preferred Pharmacy: Name, Address or Cross Streets & phone number :, Employer Name (who is sending you in ): Employer Address: City, State, Zip Code: Employer Phone: Fax: Occupation: If Personal Injury and using Health Insurance Please complete below Insurance Name: **********Please give your insurance card to the receptionist****** Are you the patient the subscriber? Yes (stop here) No (continue with Subscriber information) Subscriber s name: Subscriber s DOB: Subscriber s SSN: Patients Relationship To Subscriber: Spouse Child Other (Specify; ) If Personal Injury and using Personal Injury Protection Coverage (PIP) PIP PLAN Name: Phone: Have you had any other care for this injury to include (ambulance, dr, emergency room, etc.)? No Yes (where: ) If Personal Injury and using an Attorney: Attorney s Name: Attorney s Contact Number: 1

2 ACCIDENT HISTORY QUESTIONAIRE Name: Date: This questionnaire information is used to assist your doctor in the medical evaluation of your accident. 1. Date of Accident 2. Where were you seated?_ 3. Type of accident: Head-on collision Broad-side collision Front impact rear-end impact 4. At the time of the accident, what parts of your head or body hit what parts on the inside of the car? 5. Head/Body position at the time of impact: Head turned left/right Head straight forward Body rotated left/right Head looking back Body straight in sitting position Other: 6. Did you see the accident coming? Yes No 7. Does your car have headrests? Yes No 8. Were seatbelts worn? Yes No 9. Was your car braking? Yes No 10. Was your car moving at the time of the accident? Yes No 11. As a result of the accident, were you: Rendered unconscious Dazed, circumstances vague In Shock Other: 12. Please describe how you felt: Immediately after the accident: Later that day: The next day: 13. List injured body parts and/or areas of concern: 14. Have you missed time from work? Yes No How much time? 15. Did you seek medical help immediately after the accident? Yes No 16. What type of service have you received for your injury already? Ambulance Emergency Rm Other doctor 17. Doctor: First visit date: Were you examined? Yes No Were x-rays taken? Yes No Did you receive treatment? Yes No If yes, what kind of treatment? 18. Date of last treatment: Were you released from care? Yes No Patient Signature Date 2

3 ASSIGNMENT AND INSTRUCTION FOR DIRECT PAYMENT TO DOCTOR Patient Name: Insured s SS#: Phone: Accident Date: Address: City: Zip: Insurance/Attorney: Ins/Atty Address: Phone: Claim/Group/Policy #: Adjuster: I,, hereby instruct and direct the payment of all professional and medical expenses allowable and otherwise payable to me under my current insurance policy to: Gonzaba Medical Group 720 Pleasanton Rd. San Antonio, Tx as payment for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtness to the above mentioned assignee, and I have agreed to pay in a current manner, any balance said professional service charges over and above this insurance payment. If my current policy prohibits direct payment to doctor, then I hereby instruct and direct you to make out the check to me and mail it as follows: Gonzaba Medical Group 720 Pleasanton Rd. San Antonio, Tx A photocopy of this Assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in this case. I do realize that I remain solely responsible for the charges incurred due to this accident. Dated this day of,. Insured/Patient Print Insured/Patient Signature Guardian if patient is a minor, Print Guardian if patient is a minor, Signature Witness 3

4 Health History/Physical Exam Form Date : Patient# Name: DOB: Age: Gender: Company: Account#: HEALTH HISTORY Allergies: Medications: Tobacco Products: Alcohol: Drugs: Yes No Any Illness or injury in last 5 years? Head/Brain injuries, disorders or illness Seizures, epilepsy: medication: Eye disorders or impaired vision Ear disorders, loss of hearing or balance Heart disease or heart attack; any other vascular condition: medication: Heart surgery (valve replacement / bypass, angioplasty, pacemaker) High blood pressure: medication: Muscular Disease Shortness of Breath Lung Disease, emphysema, asthma, chronic bronchitis Kidney disease, dialysis Liver Disease Digestive problems Diabetes or elevated blood sugar controlled by: diet pills insulin Nervous or psychiatric disorders (e.g. severe depression) medication: Loss of, or altered consciousness Fainting, dizziness Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring Stroke or paralysis Missing or impaired hand, arm, foot, leg, finger, toe Spinal injury or disease Chronic low back pain Regular, frequent alcohol use Narcotic or habit forming drug use Skin disease or dermatitis Phlebitis or varicose veins requiring medical care Date: Hernia Cancer Bleeding or blood disorders Family history of (please circle) : heart disease, cancer, high blood pressure, diabetes Please explain any YES answers: 4

5 Patient Consent Form Date: Account #: Patient Name (PRINT): D.O.B. CONSENT FOR TREATMENT- As a consulting adult and/or legal guardian, I agree to permit the physicians and staff at Gonzaba Medical Group to provide medical care to myself, my child, or the patient I represent, as applicable. By signing below, I agree to permit the physician and staff at Gonzaba Medical Group to perform necessary or appropriate medical care including physical examination, diagnosis, and treatment. (initials) This is not a consent for DOT drug testing. CONSENT FOR RELEASE OF MEDICAL RECORDS- I authorize Gonzaba Medical Group to release any medical information including diagnosis, x-rays, test results, reports, and records pertaining to any treatment or examination rendered to me. I understand that this medical information may be used for any of the following purposes: diagnostic, insurance, legal, occupational medicine, continuity of care and medical treatment. (initials) ASSIGNMENT OF BENEFITS- I hereby assign all medical and/or surgical benefits, to include all major medical benefits to which I am entitled, including Medicare, private insurance and any other benefit/medical/health plan, to Gonzaba Medical Group. I understand that I am financially responsible for all charges whether or not paid by my benefit/medical/health plan. I hereby authorize Gonzaba Medical Group to release all information necessary to secure payment. (initials) I have read and understand the Authorization for Consent for Treatment, Release of Medical Records, and Assignment of Benefits. PATIENT OR LEGAL GUARDIAN SIGNATURE IF NOT PATIENT, RELATIONSHIP TO PATIENT WITNESS DATE DATE DATE 5

6 Acknowledgement of Review of Notice of Privacy Practices GONZABA MEDICAL GROUP I have reviewed and understand Gonzaba Medical Group s Notice of Privacy Practices, which explains how my medical information will be used and disclosed and how I can get access to my medical information. I know that I may have a copy of the Notice. I also know that from time to time, Gonzaba Medical Group may revise the Notice of Privacy Practices. If I want the revised notice, I know I must ask for it. Signature of Patient or Personal Representative Date Name of Patient CHART# : - DOB: Name of Authorized Personal Representative Description of Personal Representative s Authority to Act for Patient RECORD OF PROVIDER S BEST EFFORTS TO OBTAIN ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES: Is this Employee responsible for obtaining a patient signature acknowledging receipt of the group s Notice of Privacy Practices Yes No Considering the event, did you use good faith efforts to obtain the patient s signature acknowledging the Notice of Privacy Practices? Yes No Describe efforts and reason you were not able to obtain written acknowledgement: Employee Name Job Title 6