Consultants in Pain Medicine, P.A.
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- Posy Wilson
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1 Consultants in Pain Medicine, P.A. ASSIGNMENT OF BENEFITS Private insurance authorization for assignment of benefits and information release: I, the undersigned, authorize payment of medical benefits to Consultants in Pain Medicine for any services furnished to me by the physician. I understand I am financially responsible for any amount not covered by my insurance policy. I also authorize Consultants in Pain Medicine to release to my insurance company, referring physician and other consultants on my case information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits. Date Signed MEDICARE LIFETIME SIGNATURE ON FILE I request that payment of authorized Medicare benefits be made on my behalf to Consultants in Pain Medicine for any services furnished to me by the physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services. Date Signed CERTIFICATION Consultants in Pain Medicine, P.A. is pleased to offer you treatment for your injury or suffering. However, you are advised that according to most commercial insurance policies and generally accepted practice, treatment for work related chronic injuries must first be filed under Texas Workman s Compensation. We will be happy to assist you in this process. Also, if this is a litigation case, our office needs to be informed before services are rendered. I hereby certify that I am /am not seeking treatment for an illness or injury that resulted from an incident/accident at my place of work or from a motor vehicle accident. MVA / Date of Incident If applicable, Attorney s Name Phone # Print Patient Name Patient Signature Date Health Insurance Portability and Accountability Act By signing this document, I acknowledge that I have been given the opportunity to read the Notice of Privacy Practices of Consultants in Pain Medicine, P.A. Print Patient Name Patient Signature Date
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3 Information Form DATE: Name: Date of Birth: Age: Employer: Occupation: Do you work now? Yes No Part Time What does your work involve? Name of Doctor who referred you? List of other Doctors you have seen for this pain problem: Names of other Doctors you see for other medical reasons: Give details of injury or circumstances causing your pain: Were you injured on the job? Yes No How and when were you treated for this problem? Have you had surgery for this problem? Yes No If yes, give: Date Hospital Name of surgeon Tests performed: X-Rays MRI CT Scan EMG Bone Scan Discogram Other Tests Where & When: What is your pain status now? Worse Better Same Has it changed? How? What other treatments have you received? (i.e., bedrest, physical, therapy, hypnosis, chiropractic manipulation, acupuncture, injections) Please list details: Treatment: Where: When:
4 MEDICATIONS Please list medications to which you are ALLERGIC: Please list medications you have previously taken: MEDICATION HELPFUL? REASON FOR STOPPING USE Please list medications you are CURRENTLY TAKING FOR PAIN: MEDICATION DOSAGE HELPFUL? DOCTOR Please list other medications you are CURRENTLY TAKING (include vitamins, etc.): MEDICATION DOSAGE DOCTOR Please circle on a scale of 0 to 10 (0 is no pain 10 is the worst imaginable) AT ITS BEST MOST OF THE TIME AT ITS WORST
5 For the following descriptions, place a SINGLE number for each word that describes your pain: NONE = 0 MILD = 1 MODERATE = 2 SEVERE = 3 THROBBING GNAWING SPLITTING SHOOTING HOT/BURNING TIRING/EXHAUSTING STABBING ACHING SICKENING SHARP TENDER FEARFUL CRAMPING HEAVY PUNISHING/CRUEL Married? Yes No How many children do you have? Level of Education? What type of work do you do? Have you lost or gained weight in the last six months? Yes How many pounds? No Lost lbs. Gained lbs. Do you: Drink alcoholic beverages? Yes (Amt) No Smoke? Yes (Amt) No Drink caffeinated beverages? Yes (Amt) No Take vitamins? Yes No If yes, what kind? How often? Have you ever been treated for addiction? Yes No FAMILY HISTORY (Circle all that apply TO YOUR FAMILY) Asthma Genetic Disorders Kidney Problems Arthritis Headaches Lung Problems Cancer Heart Problems Seizures Diabetes High Blood Pressure Tuberculosis Other: Please circle any of the following that APPLY TO YOU Anxiety Constipation GI Bleed Heart Problems Kidney Problems Tuberculosis Arthritis Depression Glaucoma HIV Lung Problems Asthma Diabetes Hepatitis High Blood Pressure Stomach Ulcer Cancer Genetic Disorder Headaches Impotence Seizures Other: DATE PROCEDURE SURGEON HOSPITAL
6 Please mark the diagrams where you feel the symptoms described. You may have more that one body area affected by these symptoms and you may have more than one symptom in one specific area. Mark each area with each symptom you feel in each location. As an example, if the symptom is described as burning: the mark for burning is XXX, put the XXX in the area where you feel a burning sensation. You may also experience perspiration in a specific area, but nowhere else; The symbol to mark in that area on the diagram is PPP. In addition, you may feel numbness in your fingers, but dull/aching pain in your shoulder. Mark these body areas with the corresponding symbols +++ and NNN. Burning = XXX Blueness = BBB Dull/Aching = NNN Muscle Cramps = SSS Numbness = +++ Perspiration = PPP Pins & Needles = ::: Redness = RRR Stabbing/Sharp =!!! Sensitive to touch = ### Sensitive to temp. changes = 000 Swelling = *** (clothes, jewelry, pressure) (to or from indoor/outdoor: cold to hot air)
7 Consultants in Pain Medicine, P.A. 423 Treeline Park, Suite 325 San Antonio, Texas Phone (210) Fax (210) I hereby authorize Consultants in Pain Medicine, Inc., to take my photograph for inclusion in my medical chart retained by the clinic. I understand this photograph is solely for the purpose of identification and familiarization by the office staff and the clinic physician(s). Patient Signature Please fill out and sign the following release form so we can obtain copies of any medical records that may be needed in order to assess your condition more thoroughly. Date: I, hereby authorize the release of my medical records to Consultants in Pain Medicine. Patient Signature Date Witness: Date Primary Care Physician: Phone #: Fax #:
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9 CONSULTANTS IN PAIN MEDICINE, P.A. 423 Treeline Park, Suite 325 San Antonio, TX PH: (210) FAX: (210) Michael L. Murphy, M.D. Shaun C. Jackson, M.D. AUTHORIZATION FOR RELEASE OF INFORMATION Patient Name: Social Security #: / / DOB: / / I hereby authorize the release of records to: Name: Please enter complete address of recipient of records Records requested: For the purpose of: Patient Signature: Date: / / This authorization will automatically expire two (2) years from the date signed. *In order to comply with regulation for Health Insurance Portability and Accountability Act (HIPAA) governing the confidentiality of patient information, a fully completed, HIPAA compliant, Authorization to Release Medical Records must accompany each request for medical records even though you may have already obtained a signed consent from the patient. We are sorry for any inconvenience this may cause, but the laws were enacted to protect the confidentiality of medical information. Physician must comply with HIPAA privacy standards by requiring a fully completed form with all required information before releasing patient information. Thank you for your cooperation. This Authorization to Release Medical Records will expire in six months from the date of the patient s signature. *Requests with incomplete addresses will not be processed*
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11 CONSULTANTS IN PAIN MEDICINE, P.A. 423 Treeline Park, Suite 325 San Antonio, TX PH: (210) FAX: (210) Michael L. Murphy, M.D. Shaun C. Jackson, M.D. AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Patient Name: Social Security #: / / DOB: / / I hereby authorize the release of my medical records to: Consultants in Pain Medicine, P.A. Dr. Shaun C. Jackson, M.D. 423 Treeline Park, Suite 325 San Antonio, TX Fax#: Requesting medical records from: Please enter complete address Please check all that apply: Labs Progress Notes X-Rays All Medical Records Other Patient Signature: Date: / / This authorization will automatically expire two (2) years from the date signed. *In order to comply with regulation for Health Insurance Portability and Accountability Act (HIPAA) governing the confidentiality of patient information, a fully completed, HIPAA compliant, Authorization to Release Medical Records must accompany each request for medical records even though you may have already obtained a signed consent from the patient. We are sorry for any inconvenience this may cause, but the laws were enacted to protect the confidentiality of medical information. Physician must comply with HIPAA privacy standards by requiring a fully completed form with all required information before releasing patient information. Thank you for your cooperation.
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
Personal Injury Intake Form
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New England Pain Management Consultants At New England Baptist Hospital
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PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION
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City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:
Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work
WORKER S COMPENSATION HISTORY FORM NAME (Last, First, Middle Initial) Height Weight
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PATIENT INFORMATION INSURANCE INFORMATION
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PATIENT REGISTRATION
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BIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( )
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TOTAL PAIN RELIEF. Also bring your medication so that we can review them with you and help answer any question you may have.
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Work Injury Information Continued
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Insurance (Let us make a copy of your insurance card and you can skip this section)
Today s Date: Name: What do you prefer to be called: Male / Female (please circle) Birth Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Email: Referred By: Employer: How long employed:
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PATIENT REGISTRATION FORM
GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:
INITIAL PATIENT QUESTIONNAIRE-
Date: Patient Address: Home Phone: Work Phone: Age: Height: cm/inches Weight: kg/lbs Male Female Referring Physician s Name: Physician Phone: Physician Address: Type of Practice (Internist, Surgeon, etc.):
Personal Injury Questionnaire
Personal Injury Questionnaire Name Date of Birth Phone Do you want to be contacted via text: Name of cellphone carrier (ie: T-Mobile): Address City State Zip SSN: Weight & Height: Dominant hand: Employer
INTEGRATED PHYSICAL THERAPY A Holistic Approach to Physical Therapy
Patient s Name: D.O.B.: Age: Address: City: State: Zip Code: Home Phone #: Cell #: Business #: Social Security Number: E-mail Address: Height: Weight: Referring Physician? Status: Married/Single/Other/Full
PAIN MANAGEMENT. Patient s name: IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.
PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and Reports of any X- rays, MRI or Cat scans. Patient s name:
Welcome! Please fill out this Patient Registration
Welcome! Please fill out this Patient Registration Personal: (Please Print Clearly, Sign ALL pages and be Complete) Last Name First Name Middle Street City State Zip Home Phone #: ( ) Work / Cell Phone
CHIEF COMPLAINT (No, you can't just say your "husband" or "wife")
Date: / / Patient s Full Name: Home Phone: Cell Phone: E-Mail: Male Female Age: Date of Birth: / / Social Security #: - - Address: City: State: Zip: How would you like to be addressed by our staff? Married
Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail
LOUISIANA PHYSICAL THERAPY CENTERS OF PINEVILLE, LLC 1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527
1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527 Patient Information Name First Middle Last Address City State Zip Phone Other Contact Email Social Security # DOB
ADMISSION FORM PERSON WHO SIGNS CONSENT AND IS RESPONSIBLE FOR BILL. Primary Insurance: Phone: Friend/Relative? Who? Physician: Insurance:
ADMISSION FORM An Affiliate of DENVER PHYSICAL THERAPY PATIENT INFORMATION Patient Name: Address: Home Ph#: Work Ph#: Email Address: Employer Name: Employer Address: Date Injured: SS#: Marital Status:
11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
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Accident / Injury Report
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Accident / Injury Report
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Hand & Orthopedic Physical Therapy Associates, P.C.
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Function First Physical Therapy, P.C. Patient Intake Form
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460 Main St, East. Unit M3 Hamilton, ON L8N 1K4 T: 905 524 3709 F: 905 524 4866 [email protected]
Page 1 of 6 Date Patient Information (Please complete all fields below) Last Name First Name Intl. Street Address Home Tel. City/Town Province Postal Code Work Tel. Date of Birth (mm/dd/yyyy) Gender M
Questions Concerning Activities of Daily Living (ADL)
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PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
INTEGRATED PHYSICAL THERAPY a whole- istic approach to physical therapy
Patient s Name: D.O.B.: Age: Address: City: State: _ Zip Code: Home Phone #: Cell #: _ Business #:_ Social Security Number: E- mail Address: Referring Physician? _ How do you hear about us: Dr. Referral
PATIENT INFORMATION. We will not share your information. Occupation/Job: Employer: Work Address: City, State, Zip EMERGENCY CONTACT INFORMATION
PATIENT INFORMATION Date of Birth: Sex: M F Age: Soc. Sec. #: - - Photo ID #: State: Address: City, State, Zip: Mobile Phone: Home Phone: Work Phone: Email address: I want to be notified of appointments
Age: Date of Birth: S.S#: Email:
PATIENT INFORMATION Name: Date: Age: Date of Birth: S.S#: Email: Address: Street Name & Number City State Zip Home Phone #: Cellular #: Wk #: Marital Status: S M W D EMPLOYMENT INFORMATION Employer Name:
PATIENT INFORMATION PATIENT ETHNICITY / RACE SPOUSE INFORMATION EMERGENCY CONTACT
Conway Orthopaedic & Sports Medicine Clinic, PA 550 Club Lane Conway AR, 72034 501.329.1510 Account #: : Patient's Name: Patient's Street Address: Apt #: of Birth: Patient's Mailing Address/PO Box: Sex:
Personal Injury Intake Form
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Georgia Pain Management, P.C. Date:
In an effort to comply with governmental regulations regarding Meaningful Use our forms have been modified to capture additional data such as race, ethnicity, email address and contact information 03/13/2012
Motor Vehicle Accident - New Patient
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New Patient Evaluation
What area hurts you the most? (Please choose one) When did this pain start? Neck Other: Back How did this pain start? How often do you experience this pain? Describe what this pain feels like. What makes
MVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms.
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:
DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female
PATIENT DATA SHEET PATIENT INFORMATION Please complete this form in its entirety prior to your first visit. Also, please bring your insurance information and/or cards to our office at your first visit.
CHAMBERS MEDICAL GROUP 5108 15th Street East, Suite 205 * Bradenton, FL 34203 * (941) 727-9057 * (941) 727-3981 fax
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Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD
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WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
20. Please describe any pain or symptoms: a. DURING the accident: b. IMMEDIATELY AFTER the accident: c. LATER THAT DAY: d.
Name Date of Birth Phone Address City State Zip Email: Employer s Name Employer s Address Your Ins. Co. Claim # Claims Adjustors Name Driver/Owner Have you retained an attorney? ( ) Yes ( ) No If yes attorney
BOYER CHIROPRACTIC INC
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WELCOME PATIENT CONDITION
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***************PATIENT INFORMATION****************
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:
Cancellation/No Show Policy
Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You
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Welcome to Tri-State Rehab Services
Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely