Orthopedic Specialists Of SW FL New Patient Information Form

Transcription

1 Orthopedic Specialists Of SW FL New Patient Information Form Patient Name: DOB Age M or F SS# Home Ph# Cell Ph# Work# Local Address City/State Zip Code Northern/Other Address City/State Zip Code Reason for visit Date of Injury If an injury, how did this occur: Is Injury Auto or Work Related Referred By: Prim. Care Physician: Phone#: Employer Name: Occupation Spouse's Name: Spouse's DOB: Spouse's Wk#: Nearest Friend or Relative not living with you: Phone#: Health Ins. Carrier: Auto Ins. Carrier Attorney's Name Ph # If Patient Is A Minor, Parent's Name: Parent's Employer Wk Ph#: In Case Of An Emergency Notify: Phone: Pharmacy Name Phone # Patient Address I hereby authorize Orthopedic Specialists of Southwest Florida (hereinafter OSSWF ) to release any information concerning my care to my insurance company and/or any company under whose policy I am considered an insured and/or omnibus insured. I hereby irrevocably assign all insurance benefits (and/or rights to collect the same) to which I am entitled including, but not limited to, Health Insurance, Personal Injury Protection (PIP), Medical Payments, and/or Medicare benefits, to OSSWF. Moreover, I hereby direct any such insurer to make the necessary payment exclusively and directly to OSSWF in a form payable to OSSWF, only. This irrevocable assignment is given in exchange and/or in consideration for the medical treatment, care, or services rendered to the undersigned by OSSWF. Notwithstanding the granting of this irrevocable assignment, the undersigned agrees to be directly responsible to OSSWF for ALL bills for services rendered to the undersigned, and this agreement and/or assignment is made solely for OSSWF s additional protection. The undersigned agrees that payment to OSSWF for services rendered is not contingent upon any insurance claim or insurance payment but said charges are due and payable in full upon the rendering of said services. I also understand that payment is due at the time of each visit and I am personally financially responsible for the same. I authorize OSSWF to release records to any physicians and/or medical facility that they may deem pertinent to my case or care. I, and/or my representative agree not to bring frivolous medical malpractice case or cause of action against the physician or physician's legal entity providing care. Furthermore, should a meritorious medical malpractice case or cause of action be initiated or pursued, I, and/or my representative agree to use an expert medical witness who adheres to the guidelines and/or code of conduct defined by the specialty society for expert witnesses in the area of medicine who would typically have the background experience to render an opinion on such a case. (Signature) Date: Fm# /04

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4 In order to establish a complete understanding of the financial Orthopedic Specialists Of SW Florida Medical History Form Patient's name Date of Birth Age Sex M F PAST MEDICAL HISTORY - Have you been diagnosed with any of the following medical conditions? Yes no Yes no Yes no Heart Disease Yes No Blood Clots/DVT Yes No Rheumatoid Arthritis Yes No Heart Attack Yes No Bleeding Disorder Yes No Osteoarthritis Yes No Angina/chest pain Yes No Hypertension Yes No Gout Yes No Congestive heart failure Yes No Stroke Yes No Thyroid Disease Yes No COPD/Emphysema Yes No Liver Disease Yes No Tuberculosis Yes No Asthma Yes No Hepatitis Yes No HIV/AIDS Yes No Pneumonia Yes No Anemia Yes No Seizures Yes No Kidney Disease Yes No Sickle Cell Disease Yes No Anxiety Yes No Renal Failure Yes No Stomach/intestinal ulcers Yes No Depression Yes No Diabetes Yes No Cancer Yes No Fibromyalgia Yes No SURGERIES-please list all surgeries with approximate date. Problem Date Medications-List all medications with dosage and frequency, (attach list if extensive) Medication Dosage Frequency Drug and Food Allergies or adverse Reactions (include penicillin, aspirin, and anti-inflammatory drugs And local anesthesia) Patient signature Date Physician Signature Date Medical history form (cont.)

5 In order to establish a complete understanding of the financial Social History: Marital status: Single Married Divorced Widow(er) Number of children Presently living alone Yes No Do you presently smoke tobacco? Yes No If yes, please list amount you smoke: pack/day packs/week number of years smoked Do you drink alcohol regularly? Yes No If yes, please amount and type ingested per day What is your occupation? Per week Family Medical History: (do you have a family history of any of the following illnesses?) Yes No Yes No Yes No Cancer Yes No Rheumatoid Arthritis Yes No Heart Disease Yes No Diabetes Yes No Degenerative Arthritis Yes No Thyroid Disease Yes No Immune Disorders Yes No Lung Disease Yes No Kidney Disease Yes No Immunizations: (approximate date or age) Flu Tetanus Review of Systems: Are you currently having or have you had problems with any of the following? Circle Describe all Yes responses Musculoskeletal no yes (reason you are here today; ex. Joint pain, muscle pain, etc.) Weight loss/weight changes no yes Fever no yes Eyes, ears, nose, throat no yes Heart/Cardiovascular no yes Lungs/Respiratory no yes Gastrointestinal no yes Genitourinary no yes Skin no yes Neurological no yes Endocrine no yes Hematologic no yes Psychiatric no yes I certify that to the best of my knowledge the preceding information is true and accurate. Patient signature Date For office use only:

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7 Accident/Injury Detail- (this form must be completed, signed and dated) Many insurance companies require accident/injury details after they receive our claim. Please answer the following questions and explain how this accident/injury occurred. Is this claim related to an accident? NO If not due to any type of accident, please describe your symptoms; when they started, and the manner in which they started. YES Please answer the following that apply below: Date of Injury: Location of Injury (home, work, etc.): If Auto, Motorcycle, slip/fall, or Other Accident please answer the following: Auto Motorcycle ATV/Dirt Bike Bicycle Slip/Fall Other (animal bite, tools, etc.) Provide description of how accident occurred: If Auto/Motorcycle: Were you the driver or passenger? Do you own the vehicle? Yes No If motorcycle related, do you have PIP insurance that would cover medical expenses relating to this accident? Yes No Has a claim been made with your auto insurance carrier? Yes No If Work related, please answer the following: Name of employer at the time of injury: Are you self employed? Yes No Do you receive a W-2 (employee) or 1099 (subcontractor) from this employer at year end? W Have you filed a Workers Compensation claim? Yes No Has the employer or the workers compensation carrier accepted or denied liability? accepted denied Attorney Information Have you sought the assistance of an attorney relating to this accident/injury? Yes No If yes, please provide: Attorney s name: Attorney s address: Attorney s phone: To the best of my knowledge the above information is true, accurate and complete. Unanswered questions indicate they do not apply. My signature authorizes any Medicare carrier, intermediary, insurance carrier, or plan to make available to my health insurance company,, all records necessary for processing claims filed by me or on my behalf. I authorize all insurance payments, including auto, and medpay to be made directly to Orthopedic Specialists of SW Florida. Signature: Date:

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