Dana R. Towle, M.D., P.C. Hand, Wrist, Plastic and Reconstructive Surgery



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Dana R. Towle, M.D., P.C. Hand, Wrist, Plastic and Reconstructive Surgery Corporate Hills North 4444 N. Belleview Suite 204 Kansas City, MO 64116 Phone: (816) 452-8080 Fax: (816) 878-6055 Dear, Thank you for contacting our office to schedule an appointment with Dr. Dana R. Towle. Enclosed you will find a HIPPA privacy form, patient information sheets and a map to our office. Please bring completed paperwork to your appointment, this will save you time and will allow us to get you in to see the doctor in a timely manner. We have scheduled your appointment for at. If your insurance requires a referral please make sure that we have this before your appointment. It is your responsibility to get us your referral. If you have seen another physician concerning this problem and/or have had any tests done, please be sure to have your pertinent medical records and EMG, x-ray and/or MRI reports sent to our office prior to your appointment. X-ray/MRI films, insurance cards and drivers license must be brought with you at the time of your appointment. Without this information Dr. Towle will be unable to see you. Dr. Towle is a specialist, if your insurance requires a co-payment this will need to be paid at the time of your appointment. If you are a workman s compensation patient, we will need to know your case worker s name, phone number, fax number, claim number, and billing information prior to you setting your appointment. We will not be able to see you if you arrive for your worker s compensation appointment and we have not received prior approval from your worker s compensation insurance company. A missed appointment can pose a health risk to you as well as impact Dr. Towle s schedule. Our office has a 24 hour cancellation policy. If you do not cancel within 24 hours of your appointment you will be charged $35.00 (referred to as a no-show fee). This charge cannot be billed to your insurance company and will be your responsibility. Failure to pay this no-show fee will be treated according to our policy on unpaid balances. Therefore, please notify our office if you cannot keep your scheduled appointment. Sincerely, The medical staff of Dr. Dana R. Towle, M.D., P.C. E-mail: info@towlemd.com Website: www.towlemd.com

Phone (816) 452-8080 Dana R Towle, MD, PC Fax (816) 878-6055 4444 North Belleview, Suite 204 North Kansas City, MO 64116 PATIENT PERSONAL INFORMATION: Patient s Name: First Middle Last Sex Patient s Date of Birth Age Patient s Social Security # Martial Status Physical Address where patient lives Apt # City State Zip Home Phone #_( ) Cell Phone #_( ) Patient s Employer Employer s Phone #_( ) Employer s Address Family(PCP)Physician _ Occupation City State Zip Physician s Phone #_( ) Physician s Fax #_( ) Referring Physician Physician s Phone #_( ) Physician s Fax #_( ) Pharmacy s Name Pharmacy s Address Pharmacy s Phone #_( ) Pharmacy s Fax #_( ) Emergency Contact (not living with you) Address City State Zip Relationship Phone #_( ) SPOUSE S INFORMATION: Spouse s Name Home Phone #_( ) Spouse s Social Security # Cell Phone #_( ) Spouse s Address (if different from above) Employer Phone #_( ) Employer City State Zip Employer Address Spouse s Date of Birth City State Zip MEDICAL INSURANCE INFORMATION (must be completed, NO Exceptions): Primary Insurance Secondary Insurance Name of Ins Subscriber s Name Date of Birth Policy/ID # Group # Employer s Name Relationship to patient Group Name Name of Ins Subscriber s Name Date of Birth Policy/ID # Group # Employer s Name Relationship to patient Group Name WORKMAN S COMPENSATION INFORMATION: (We must have approval from a case manager prior to appointment-which means you must have filed a claim with your employer) Name of Work Comp Insurance Carrier Adjuster/CaseManager Billing Address Claim # City State Zip Phone # ( ) Fax # ( _ ) Date of Injury Authorization/Assignment/Release of Information: I, hereby assign all medical and/or surgical benefits to which I am entitled, including Medicare, private, HMO/PPO, Workman s Compensation and commercial insurances as well as third party payors be made on my behalf to Dana R. Towle, MD, PC, for any services furnished to me or my family by Dana R. Towle, MD, PC. I hereby authorize said assignee to release all information necessary, including Medical Records, to secure payment or for determination of benefits payable for related services. A photocopy of this assignment is to be considered as valid as the original. I agree to be photographed by Dana R. Towle, MD, PC, for the purpose of medical requirements and medical authorization. Signature of Patient or Legal Guardian/Parent Relationship Date

Phone (816) 452-8080 Dana R Towle, MD, PC Fax (816) 878-6055 4444 North Belleview, Suite 204 North Kansas City, MO 64116 Today s Date Legal Name: Height: Weight: _ Reason for being seen today: Injury or Accident: YES NO Date of Injury: State accident occurred in: How injury occurred: Tobacco Use: 0 None 0 Previous 0 Current Amount used daily Alcohol Consumption: 0 None 0 Occasionally 0 Heavy Past Medical History-Do you have a history of: 0 Heart Disease 0 Pneumonia 0 Arthritis 0 Myocardial Infarction (Heart Attack) 0 Emphysema or Asthma (circle one) 0 Diabetes 0 Heart Rhythm Problems 0 Tuberculosis 0 Psychiatric Illness 0 Bleeding Disorders 0 Kidney Disease 0 Seizures 0 Stroke 0 Aids or HIV Positive Status 0 Thyroid Disease 0 Mitral Valve Prolaspe 0 Cervical Spine Problems 0 Congenital (Birth) Defects 0 Other Major Illnesses (please explain below) Comments (Other Major Illnesses): Past Surgeries or Trauma History (please write the date next to surgery): 0 Hand/Wrist Surgery (explain below) 0 Spine Surgery 0 Coronary Artery Bypass Grafting/Stenting 0 Gynecological Procedures 0 Lung Surgery 0 Excessive Bleeding 0 Cholecystectomy (Gall Bladder) 0 Anesthesia Difficulties 0 Appendectomy 0 Other Surgeries (please explain below) Other: Family Medical History (i.e. Heart Disease, Stroke, Cancer, Diabetes, Thyroid, etc) please explain below: Systems Review (circle all that apply for EACH system): Eyes: blurred vision eye pain watering eyes NONE Head/Neck: hearing difficulty tinnitus headache difficulty with taste, smell, or swallowing NONE Cardiovascular: chest pain palpitations edema dizziness NONE Respiratory: shortness of breath wheezing sputum production cough NONE Gastrointestinal: heartburn abdominal pain nausea vomiting change in bowel habits blood in stool NONE Genitourinary: pain when urinating blood in urine frequency urgency incontinence excessive urination at night NONE Neurological: weakness numbness tremors NONE Hematologic/Lymphatic: swollen nodes excessive bleeding excessive bruising NONE Integumentary: skin rash itching burning skin dryness lesions/ulcers nail changes NONE Musculoskeletal: stiffness pain in hand or arm swelling in hand or arm NONE Psychiatric: depression hallucinations sleep changes alcohol/drug problems NONE Signature of Patient or Legal Guardian/Parent Relationship Date

Phone (816) 452-8080 Dana R Towle, MD, PC Fax (816) 878-6055 4444 North Belleview, Suite 204 North Kansas City, MO 64116 Where can we leave a message to notify you of your appointments and/or test results? (Circle all that apply) Home Cell Work In accordance with patient confidentiality and privacy laws, we will need your written permission to discuss appointments, test results, medical records, prescriptions and your account information with anyone other than yourself. Please LIST BELOW ANYONE you give permission to access your information (including billing/account balance information) by phone, fax or mail. l:i No one (I understand this includes spouse/doctors/etc) l:i Workman s Compensation Representative l:i Pharmacy (any) l:i Disability Representative l:i Family Physician l:i Referring Doctor l:i Attorney l:i Other (We are required to send all reports to referring doctors, no matter what is marked here) I understand that I have the right to revoke this authority at anytime, but I must do so in writing. The revocation does not apply to any information already released. Signature of Patient or Legal Guardian/Parent Relationship Date I hereby acknowledge that I have been presented a copy of Dana R. Towle, MD, PC s, Notice of Privacy Practice. Initial Date FINANCIAL POLICY STATEMENT We bill your insurance carrier solely as a courtesy to you. You are responsible for the entire bill for services rendered. Your Co-pay is due at the time of service, keep in mind that Dana R. Towle, MD, PC is a specialist. If your insurance carrier does not remit payment within 60 days, the balance will be due in full from you. You also understand that you are responsible for any amount not covered by your insurance. In the event that your insurance company requests a refund of the payment made, you will be responsible for the entire charge amount. If any payment is made directly to you for services billed by Dana R. Towle, MD, PC, you recognize an obligation to promptly remit same, with remittance advice to Dana R. Towle, MD, PC. The above does not apply for those patients approved by Workman s Compensation. However, be advised if your claim/benefits are subsequently denied, you will be held responsible for the total amount of charges for services rendered to you. If this is possibly a work related issue authorization must be received from your case manager or adjuster prior to your appointment. Please be advised that Dana R. Towle, MD, PC does not handle Attorney/Liability Insurance liens for medical services rendered. We do not wait on settlement to receive payment. Payment is expected when services are rendered. If you do not have insurance, payment is expected when services are rendered. If payment in full is not possible at the time services are rendered, payment arrangements may be made in advance by contacting an insurance coordinator. I authorize Dana R. Towle, MD, PC or his staff to initiate a complaint to the Insurance Commissioner for any reason on my behalf. I understand and agree that if I fail to make payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, interest, and attorney fees. I understand that there is a $35.00 charge for my appointments that are not cancelled within 24 hour notice of my appointment time. I understand that this charge can not be billed to the insurance company and will be my responsibility. Failure to pay a no-show fee will be treated according to Dana R. Towle, MD, PC policy on unpaid balances. Medical care will not be withheld for a medical emergency. I understand that if appointments are repeatedly missed, Dana R. Towle, MD, PC may be forced to dismiss me from his practice. Dana R. Towle, MD, PC accepts payments in the form of Credit Card (American Express, Discover, Visa and MasterCard), cash, money order, and personal check. I understand there will be a $25.00 service charge for any returned checks and personal checks will no longer be accepted from me, I must continue to pay with credit card, cash or money order. I understand that there is a charge for Dana R. Towle, MD, PC or his staff to complete any Disability or Family Medical Leave Act (FMLA) forms. The charge is $30.00 per form for a 5 day turnaround. If you need the form prior to 5 days it will be $40.00 per form. I understand that the fee for the form to be completed must be paid at the time the form is received by Dana R. Towle, MD, PC or his staff. I have read the above information. I UNDERSTAND MY RESPONSIBILITIES FOR THE PAYMENT OF MY ACCOUNT. Signature of Patient or Legal Guardian/Parent Relationship Date Dana R. Towle, MD, PC Representative Signature (verified)

Phone (816) 452-8080 Dana R Towle, MD, PC Fax (816) 878-6055 4444 North Belleview, Suite 204 North Kansas City, MO 64116 PATIENT MEDICATION LIST PATIENT NAME: DOB: MEDICATION DOSAGE HOW MANY TIMES DAILY REASON FOR TAKING MEDICATION ALLERGIES (ENTER N/A IF NO KNOWN ALLERGIES) ALLERGY REACTION

Name: Accident/Injury History Dana R Towle, MD 4444 N Belleview Dr., Ste. 204 Kansas City, MO 64116 Ph: 816-452-8080 Fax: 816-878-6055 Accident Form Date of Birth: 1. Date of accident/injury: Gradual Sudden Progressive 2. Address/location where you were injured: 3. Time of day when accident occurred: am/pm Date last worked: 4. If work comp, did you report this to your employer? Yes/No If so, to whom: 5. Did you go to the hospital or another doctor s office after the accident? Yes/No If so, where? What type of treatment was administered? Was a diagnosis made? Yes/No If so, what was it? 6. Describe how the accident/injury happened: Were X-rays taken? Yes/No 7. What is your number-one problem or the one area of greatest pain? 8. Have you experienced this problem before? Yes/No If so, when? 9. Rate the level of this pain of the following scale: (0 is no pain, 10 is severe) 0 1 2 3 4 5 6 7 8 9 10 10. How often do you experience this pain? 1-2 hours per day About half of the day Most of the day Constant 11. How does the pain affect your daily activities? It does not affect my daily work or home activities. I have had to change how I do my work or home activities. How: I cannot do the following due to my present problem: I am unable to do nearly everything I am accustomed to doing. 12. Do you feel you could perform your usual job right now? Yes/No 13. Describe your routine job duties:

14. If you are working, how has your current condition affected your normal duties? 15. Is there any activity or duty you are unable to perform? 16. How often does your job require you to do the following? Lifting ( lbs) Standing (_ hrs/day) Telephone (_ hrs/day) Sitting (_ hrs/day) Computer (_ hrs/day) Driving ( hrs/day) Push/pull ( once in a while often frequently all the time) Reach overhead (_ once in a while often frequently all the time) Grasping (_ once in a while often frequently all the time) Twisting/bending (_ once in a while often frequently all the time) Squatting/kneeing (_ once in a while often frequently all the time) Walking (_ once in a while often frequently all the time) Climbing/ladders (_ once in a while often frequently all the time) Other, please explain: 17. Please add anything you would like the doctor to know: Authorization I certify that I have read and I understand the above information to the best of my knowledge. I have answered all questions accurately and understand that by providing false information my health could be in danger. I authorize Dana R Towle, MD, PC to release any information regarding the diagnosis and the records of treatment to third party payors, therapy providers and/or other health practitioners. I authorize and request my insurance company to pay benefits directly to Dana R Towle, MD, PC. If I am filing a worker s compensation claim, I understand it can be denied. If my claim is denied, I agree to be responsible for payment of all services rendered on my behalf. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers compensation benefits or payments is guilty of a felony. Patient s Signature: Date:

DIRECTIONS Driving North: I-29 North take the Vivion Road/Highway 69 exit (1-E). Turn left (West) onto Vivion Road. Drive under the I-29 overpass and take the first left (South) onto North Belleview. Continue up the hill thru Claymont Pointe Housing Division to Corporate Hills North. Driving South: I-29 South take the Vivion Road/Highway 69 exit (1-E). Turn left (West) onto Vivion Road. Take the first left (South) onto North Belleview. Continue up the hill thru Claymont Pointe Housing Division to Corporate Hills North. CORPORATE HILLS NORTH Driving North from Downtown Kansas City Area: Take the Broadway Extension North (also 169 North) to the Vivion Road exit. Turn Right onto Vivion Road. Take the first right (South) onto North Belleview. Continue up the hill thru Claymont Pointe Housing Division to Corporate Hills North. Driving East From Overland Park Area: Take I-35 north to 635 North (towards the Airport). I-29 South take the Vivion Road/Highway 69 exit (1-E). Turn left (West) onto Vivion Road. Take the first left (South) onto North Belleview. Continue up the hill thru Claymont Pointe Housing Division to Corporate Hills North. Driving West From Independence Area: Take I-70 West to 435 North. Take I-35 South to I-29 North take the Vivion Road/Highway 69 exit (1-E). Turn left (West) onto Vivion Road. Drive under the I-29 overpass and take the first left (South) onto North Belleview. Continue up the hill thru Claymont Pointe Housing Division to Corporate Hills North. Upon arriving at the Corporate Hills North office, drive to South (left) side of the building and use the double door entrance to the second level. Suite 204 is the first door on the left KANSAS CITY METRO AREA

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