***************PATIENT INFORMATION****************

Transcription

1 SEP BADY, MD ***************PATIENT INFORMATION**************** TODAYS DATE: / / WHICH DOCTOR ARE YOU SEEING? BADY KURUVILLA LIU OTTEN TRAINOR YEE PATIENT LAST NAME: FIRST: MIDDLE INITIAL: ADDRESS: CITY/STATE: ZIP: HOME PH: ( ) WORK PH: ( ) CELL PH: ( ) SSN: SEX: M F DATE OF BIRTH: / / AGE: MARITAL STATUS: MARRIED SINGLE DIVORCED SEPARATED WIDOWED PARTNERED IF PATIENT IS A MINOR: PARENT/GUARDIAN LAST NAME: FIRST NAME: EMPLOYER: OCCUPATION: EMPLOYER ADDRESS: CITY/STATE: ZIP: ********************INSURANCE INFORMATION****************** PRIMARY INSURANCE CO NAME: PHONE: ( ) ADDRESS TO MAIL CLAIMS: CITY/STATE: ZIP: POLICY HOLDER: LAST NAME: FIRST NAME: M. IN: SSN: DATE OF BIRTH: / / RELATION TO PATIENT: POLICY/ID#: GROUP#: EMPLOYER: SECONDARY INSURANCE CO NAME: PHONE: ( ) ADDRESS TO MAIL CLAIMS: CITY/STATE: ZIP: POLICY HOLDER: LAST NAME: FIRST NAME: M.IN: SSN: DATE OF BIRTH: / / RELATION TO PATIENT: POLICY/ID#: GROUP#: EMPLOYER:

2 SEP BADY, MD *******************IF PATIENT IS A MINOR GUARANTOR INFORMATION****************** PERSON RESPONSIBLE FOR BILL S LAST NAME: FIRST: ADDRESS: CITY: STATE: ZIP: HOME PH: ( ) WORK PH: ( ) CELL PH: ( ) SSN: SEX: M F DATE OF BIRTH: / / AGE: ********************************EMERGENCY CONTACT******************************* NAME OF LOCAL FRIEND OR RELATIVE: LAST NAME: FIRST NAME: RELATIONSHIP: HOME PH: ( ) WORK PH: ( ) CELL PH: ( ) The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I hereby assign my healthcare benefit payments, to which I am entitled through my insurance company to Advanced Orthopedics and Sports Medicine. This assignment is pursuant to the Employee Retirement Income Security Act (ERSA) as defined in 29 CFR , and applicable State law, and it will remain in the effect until revoked by me in writing. I understand that I am that I am financially responsible for all the charges not paid by my insurance. I hereby authorize said assignee to release all information necessary to secure the payment of said benefits. Advanced Orthopedics and Sports Medicine is hereby authorized to initiate on my behalf any complaints regarding my healthcare benefit payments or adverse benefit determinations as defined in 29 CFR , with the State Insurance Commissioner for a possible violation of State Insurance Laws or the Employee Benefits Security Administration and the Secretary of Labor as it pertains to ERISA, specifically 29 USC (a) and 1144(a). Advanced Orthopedics and Sports Medicine is allowed full discovery of any and all information, documentation, policies, procedure and resources used by my insurance company, to perform an adverse benefit determination, as defined in 29 CFR of my covered health benefits. Advanced Orthopedics and Sports Medicine is authorized to represent me in any and all Federal Lawsuits against my insurance company pursuant to the ERISA> A copy of this document is as valid as the original. / /

3 PLEASE COMPLETE THIS FORM IF THE FOLLOWING APPLIES: SEP BADY, MD AUTO ACCIDENT WORKMAN S COMP THIRD PARTY LIABILITY ATTORNEY LIEN PLEASE FILL OUT THIS FORM TO GIVE YOUR INSURANCE COMPANY THE INFORMATION THEY NEED TO PROCESS YOUR CLAIM WITHOUT DELAY. YOUR CLAIMS WILL BE SUSPENDED BY YOUR INSURANCE COMPANY UNTIL THEY RECEIVE INFORMATION ON THE DETAILS BEHIND YOUR INJURY. GENERAL INFORMATION 1. INJURED PATIENT S NAME (LAST, FIRST) 2. HOW DID THE INJURY OCCUR?: 3. DATE INJURY OCCURRED: / / STATE WHERE INJURY OCCURRED? TRAFFIC ACCIDENT: IF IN AN AUTO ACCIDENT, WERE YOU: DRIVER PASSENGER FRONT PASSENGER REAR MOTORCYCLE DRIVER MOTORCYCLE PASSENGER WERE YOU WEARING A SEATBELT AT THE TIME OF ACCIDENT? YES NO CAR INSURANCE CO NAME: CLAIM NUMBER: NAME OF ADJUSTOR: PHONE: ( ) SLIP/FALL, MISHAP INJURY, DOG BITE: GIVE DETAILS OF INJURY INCLUDING BUSINESS OR HOMEOWNER WHERE INJURY OCCURRED: HAVE YOU HIRED AN ATTORNEY TO REPRESENT THIS CLAIM? YES NO LAWYER S NAME/OFFICE: PHONE: ( ) WORKMAN S COMPENSATION/ON THE JOB INJURY: WE MUST HAVE COMPLETE AND ACCURATE INFORMATION IN ALL SECTIONS! PLEASE ASK FOR ASSISTANCE WITH PHONE BOOKS, OR PHONE CALLS IF NEEDED FOR ADDRESSES AND PHONE NUMBERS. EMPLOYER AT TIME OF INJURY: SUPERVISORS NAME: ADDRESS: CITY/STATE: ZIP PHONE: ( ) DATE LAST WORKED FOR THIS EMPLOYER: / / (MM/DD/YYYY) DATE OF INJURY: / / (MM/DD/YYYY) BODY PART(S) INVOLVED: R L EXPLAIN HOW INJURY OCCURRED: CLAIMS ADMINISTRATOR CO: CLAIM#: ADJUSTORS NAME: PHONE: ( ) EXT: CLAIMS ADDRESS: CITY/STATE: ZIP / /

4 PATIENT NAME (LAST, FIRST): DATE OF BIRTH: / / HAVE YOU PREVIOUSLY SEEN A PHYSICIAN FOR WHAT WE ARE TREATING YOU FOR TODAY? (IF YES, PLEASE EXPLAIN BELOW): YES NO DO YOUR OTHER JOINTS HAVE: MORNING STIFFNESS LASTING OVER 30 MINUTES JOINT PAIN OR SWELLING GOUT BACK PAIN RHEUMATOID ARTHRITIS OSTEOPOROSIS PRIOR FRACTURE OF NONE HAVE YOU HAD ANY OF THESE SYMPTOMS? NONE YEAR GI HEARTBURN, ULCERS NAUSEA, VOMITING BLOOD IN STOOL HEPATITIS LIVER DISEASE ENDO THYROID DISEASE HEAT OR COLD INTOLERANCE CON WEIGHT LOSS LOSS OF APPETITE EYE BLURRED VISION DOUBLE VISION VISION LOSS ENT HEARING LOSS TROUBLE SWALLOWING HOARSENESS CV CHEST PAIN PALPITATIONS RS CHRONIC COUGH SHORTNESS OF BREATH GU PAINFUL URINATION BLOOD IN URINE KIDNEY PROBLEMS SK FREQUENT RASHES SKIN ULCERS LUMPS PSORIASIS NEU HEADACHES DIZZINESS SEIZURES PSY DEPRESSION DRUG/ALCOHOL ADDICTION SLEEP DISORDER HEM EASY BLEEDING EASY BRUISING ANEMIA ARE YOU HIV POSITIVE? YES NO PAST MEDICAL HISTORY ARE YOU DIABETIC? YES NO IF YES, TREATMENT: INSULIN ORAL MEDS DIET NONE ARE YOU TAKING, OR HAVE YOU EVER TAKEN BLOOD THINNERS? YES NO IF YES, WHICH ONE? PAST SURGICAL/MEDICAL HISTORY INCLUDES: (LIST MAJOR SURGERIES AND/OR MAJOR ILLNESSES) 1) DATE: / / DOCTOR/STATE: 2) DATE: / / DOCTOR/STATE: 3) DATE: / / DOCTOR/STATE: 4) DATE: / / DOCTOR/STATE: PAST HOSPITALIZATIONS (NOT FOR SURGERY): NONE HAVE YOU EVER HAD HEART ATTACK (YEAR: ) HEART FAILURE HIGH BLOOD PRESSURE KIDNEY FAILURE STROKE BLOOD CLOTS (YEAR: ) ANKLE SWELLING CANCER (LOCATION: ) DO YOU GET STOMACH ACHES WHILE TAKING ANTI-INFLAMMATORIES (ADVIL/ALEVE, ETC. ) YES NO CONTINUED ON FOLLOWING PAGE

5 FAMILY HISTORY HAVE ANY IMMEDIATE RELATIVES HAD ANY OF THE FOLLOWING DISORDERS? DIABETES HIGH BLOOD PRESSURE RHEUMATOID ARTHRITIS IF YES, WHICH FAMILY MEMBER? DO ANY DIRECT RELATIVES HAVE THE SAME CONDITION YOU ARE BEING SEEN FOR TODAY? YES NO SOCIAL HISTORY DO YOU USE TOBACCO? YES NO PREVIOUSLY IF YES, TYPE: PACKS PER DAY: ALCOHOL USE? YES NO IF YES: LESS THAN 1 DAILY 1 DAILY 2-3 DAILY 4+ DAILY DO YOU EXERCISE REGULARLY? YES NO IF YES, HOW OFTEN? CURRENT WEIGHT: POUNDS HEIGHT: FT IN CURRENT MEDICATIONS ALLERGIES TO MEDICATIONS OR MEDICAL PRODUCTS (I.E. LATEX, IV DYE, ETC.) PLEASE SIGN TO VERIFY THAT THE INFORMATION ON THESE FORMS IS ACCURATE TO THE BEST OF YOUR KNOWLEDGE. / /