Mississippi Sports Medicine & Orthopaedic Center, PLLC AND The Therapy Center of Mississippi Sports Medicine HISTORY + PHYSICAL Name: Date: Age: Social Security Number: Height: Weight: Please circle affected extremity: Ankle Finger Back Foot Elbow Knee Hand Hip Shoulder Toe Wrist PLEASE CIRCLE: Left Right Both When did this injury/problem begin? (Date: Please try to be as specific as possible.) / / Please describe how you were injured or what type of problems you are having now. Describe your level of pain: None Severe Describe your frequency of pain: None 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 Any Previous Problems or Injuries? Yes No If Yes Please describe: Is this a Work injury? Yes No Is Worker s Comp Involved? Yes No Always Is this a Sports injury? Yes No If Yes, what Sport? What is your level of play? (Please circle one) Junior High High School College Professional Recreational Was this an Accident? Yes No Type of Accident: Motor Vehicle Accident Fall Other (Be Specific) Have you been treated previously for this injury? Yes No Physician: City/State Hospital: City/State Circle ANY previous treatments and/or testing for this problem: X-Rays CT Scan MRI Physical Therapy Injections Surgery Office use only: Physician/Nurse Signature required (initial & date)
Mississippi Sports Medicine & Orthopaedic Center, PLLC AND The Therapy Center of Mississippi Sports Medicine CURRENT MEDICAL HISTORY Name: Date: Age: Date of Birth: Sex: Occupation: Who is your family Doctor? City/State: Who referred you here? Do you have any of the following medical conditions? (Circle all that apply) High Blood Pressure Kidney Disease Liver Disease Lung Disease Asthma Bleeding Disorder Sickle Cell Osteoporosis Diabetes Poor Healing Ulcers Heart Disease/Problems Cancer Gout HIV / AIDS Rheumatoid Arthritis Osteoarthritis Other: Does anyone in your immediate family have any of the following medical conditions? (Circle all that apply) High Blood Pressure Kidney Disease Liver Disease Lung Disease Asthma Bleeding Disorder Sickle Cell Osteoporosis Diabetes Poor Healing Ulcers Heart Disease/Problems Cancer Gout HIV / AIDS Rheumatoid Arthritis Osteoarthritis Other: Please indicate which family member: Please list all medications, dosages, and frequencies that you currently take: (Include all over the counter medications and vitamins) Do you take Blood Thinners? No Yes Are you allergic to any medications? No Yes If yes, list medications and type of reaction: Please list any and all previous surgeries that you have had: (Include date and name of surgeon) Do you smoke cigarettes? Yes No I have never smoked - No, I quit more than 6 months ago - No, I quit in the last 6 months
Mississippi Sports Medicine and Orthopaedic Center, PLLC AND The Therapy Center of Mississippi Sports Medicine Patient Demographic & Insurance Information Patient s Social Security Number: Account Number: Patient s Legal Name: First Middle Last Birth Date: Gender F M Street Address: Apt/Suite City: State: Zip: Mailing Address: _ (If Different From Above) P.O. Box City State Zip Home Phone: ( ) Cell Phone: ( ) Work Phone: ( ) E-mail: Responsible Party Demographic Information Patient s Relationship to Responsible Party: Self Child Spouse Guardian Other Name of Responsible Party: First Middle Last Street Address: Apt/Ste. City: State: Zip: Mailing Address: (If Different From Above) P.O. Box City State Zip Birth Date: Gender F M Social Security Number: Home Phone: ( ) Cell Phone: ( ) Employer Name: Employer Address: Employer Phone: Ext: Primary Insurance Coverage Information Name of Insurance: Policy Number: Effective Date: Group Name: Group Number: Primary Care Physician: Phone Number: Patient s Relationship to Insured: Self Child Spouse Guardian Other Name of Policy Holder: First Middle Last Policy Holder Birthdate: Policy Holder Social Security Number: Policy Holder Employer: Gender: M F I hereby authorize payment directly to Mississippi Sports Medicine and Orthopaedic Center, PLLC or The Therapy Center of Mississippi Sports Medicine, for medical services rendered. I authorize the release of my medical information deemed necessary in the processing of a claim. It is my understanding that I am responsible for this amount, regardless of insurance coverage. I have received a copy of the Mississippi Sports Medicine and Orthopaedic Center s Privacy Policy. Date: Signature:
Secondary Insurance Coverage Information Name of Insurance: Policy Number: Effective Date: Group Name: Group Number: Primary Care Physician: Phone Number: Patient s Relationship to Insured: Self Child Spouse Guardian Other Name of Responsible Party: First Middle Last Policy Holder Birth date: Policy Holder Social Security No. Policy Holder Employer: Gender: F M Additional Patient Information Marital Status: Single Married Divorced Separated Widowed Patient s Employment Status: Full-time Part-time None (Name of Employer) Spouse s Employment Status: Full-time Part-time None (Name of Employer) Student Status (if applicable): Full-time Part-time None (Name of School) Referral Physician/Referral Source: Emergency Contact Information Name: City: Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Name: City: Cell Phone: ( ) Home Phone: ( ) Work Phone: ( ) Injury Information What doctor are you seeing today? Dr. Almand Dr. Barrett Dr. Burrow Dr. Craft Dr. Ethridge Dr. Field Dr. Hobgood Dr. Johnson Dr. Lawin Dr. Mehrle Dr. O Mara Dr. Pickering Dr. Ramsey Dr. Shelton What specific part(s) of the body are we treating? (please include left or right) Specific date of when this injury/problem began / / Is this injury/problem due to a: work related accident motor vehicle accident sports related accident fall Has this injury/problem resulted in liability/litigation? Yes No other: TERMS OF SERVICE: PROFESSIONAL SERVICES ARE RENDERED AND CHARGED TO THE PATIENT. PAYMENT IS EXPECTED AT THIS TIME. INJURIES RESULTING FROM MOTOR VEHICLE ACCIDENTS OR OTHER ACCIDENTS ARE NO EXCEPTION. OUR CLINIC DOES NOT ACCEPT THE RESPONSIBILITY OF COLLECTING OR NEGOTIATING SETTLEMENT ON A DISPUTED CLAIM. IF THE INSURANCE OR DISPUTED CLAIM HAS NOT BEEN PAID WITHIN 45 DAYS THE PATIENT IS EXPECTED TO MAKE ARRANGEMENTS FOR PAYMENT. I UNDERSTAND THE TERMS OF SERVICE AND AGREE TO ITS CONTENT. Date: Signature:
Mississippi Sports Medicine and Orthopaedic Center, PLLC AND The Therapy Center of Mississippi Sports Medicine Pharmacy Information Preferred Pharmacy: Name Address: City St. Zip Phone Federal Government Mandated Ethnicity Information Language best served in: English French German Japanese Spanish Other Unreported/Refused to Report Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Unreported/Refused to Report Ethnicity: Hispanic/Latino Non Hispanic/Latino Unreported/Refused to Report Unreported/Refused to Report - All of the Above Military Status Information Are you a Veteran or Currently Serving in the Military Yes No Unknown Today s Date: Patient Name: Date of Birth: Signature:
MISSISSIPPI SPORTS MEDICINE & ORTHOPAEDIC CENTER, PLLC 1325 East Fortification Street, Jackson, Mississippi 39202 P.O. Drawer 16870, Jackson, Mississippi, 39236-6870 (601) 354-4488 Toll Free 1-800-624-9168 www.msmoc.com Jeff D. Almand, M. D Gene R. Barrett, M.D. Jamey W. Burrow, M.D. Jason A.. Craft, M.D. Chris P. Ethridge, M.D. Larry D. Field, M.D. Rhett Hobgood, M.D. Brian P. Johnson, M.D. Penny J. Lawin, M.D. Robert K. Mehrle, M.D. James W. O Mara Jr., M.D. Trevor Pickering, M.D. J. Randall Ramsey, M.D. Walter R. Shelton, M.D. J.O. Manning, M.D., Emeritus We at Mississippi Sports Medicine strive to make your visit a pleasant one. Our Staff is here to help ensure your claims are paid in a timely manner. We need your assistance in getting your claims paid. please take a minute and read the information below. IMPORTANT INSURANCE INFORMATION If your visit is due to an injury, your assistance company may require additional information from the patient. Your Insurance Company will mail the patient or the guarantor a form to fill out. If this form is NOT filled out, the claim is usually denied pending this information and will be the patient s responsibility. You should receive this request within 30 days of your visit. IF YOU DO NOT RECEIVE AN INJURY FORM OR AN EXPLANA- TION OF BENEFITS (details, what has been paid or denied by your Insurance Company) PLEASE CONTACT YOUR INSURANCE COMPANY. If your injury is due to an auto accident, we need a letter from your Auto Insurance stating you have exhausted your med pay. We will need this letter to file your claim to your health insurance. Please let our front desk know if your insurance has changed since your last visit with Mississippi Sports Medicine. Keeping us informed of any changes will help us in filing your claim correctly and in a timely manner. Please always use your legal name. If your name on the card and the name That you give DO NOT match, we WILL NOT BE ABLE TO FILE your claim.
Mississippi Sports Medicine and Orthopaedic Center, PLLC 1325 East Fortification St. Jackson, MS 39202 NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. Mississippi Sports Medicine and Orthopaedic Center is dedicated to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. Mississippi Sports Medicine and Orthopaedic Center is required by law to abide by the terms of this Notice, and we reserve the right to change the terms of this Notice, making any revision applicable to all the protected health information we maintain. If we revise the terms of this Notice, we will post a revised notice at the Hospital and will make paper copies of this Notice of Privacy Practices for Protected Health Information available upon request., HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED: We will securely store your medical information on a computer for use as part of rendering patient care. For example, your medical information may be used by the health care professional treating you, by the business office to process your payment for the services rendered and by administrative personnel reviewing the quality and appropriateness of the care you receive. We may also use and/or disclose your information in accordance with federal and state laws for the following purposes: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may disclose medical information when required by the United States Department of Health and Human Services as part of an investigation or determination or the Hospital's compliance with relevant laws. Unless you object, we will include general information, including your name, location in the hospital, your condition described in general terms and your religious affiliation in a directory of individuals located in the Hospital. The directory information, except for your religious affiliation, will be released to people who ask for you by name. Your religious affiliation may be given to members of the clergy, even if they do not ask for you by name. Unless you object, we may disclose to family members, other relatives or close personal friends the medical information directly relevant to such person's involvement with your care. Unless you object, we may use or disclose your medical information to notify a family member, a personal representative or another person responsible for your care of your location, general condition or death. We may disclose your medical information to a public or private entity for the purpose of coordinating with that entity to assist in disaster relief efforts. We may use or disclose your medical information for public health activities, including the reporting of disease, injury, vital events and the conduct of public health surveillance, investigation and/or intervention. We may disclose your medical information to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure or disciplinary actions, administrative and/or legal proceedings.
We may disclose your medical information in the course of certain judicial or administrative proceedings. We may disclose your medical information for law enforcement purposes or other specialized governmental functions. We may disclose your medical information to a coroner, medical examiner or a funeral director. If you are an organ donor, we may disclose your medical information to an organ donation and procurement organization. We may disclose your medical information for certain research purposes. We may use or disclose your medical information to prevent or lessen a serious threat to the health or safety of another person or the public. We may disclose your medical information as authorized by laws relating to workers' compensation or similar programs. We will not use or disclose your medical information for any other purpose without your written authorization. Once given, you may revoke your authorization in writing at any time. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION: You have the following rights with respect to you medical information. The right to request restrictions on certain uses and disclosures of your medical information. We are not required to agree to your requested restriction, but if we do, we will honor it. The right to receive communications from us in a confidential manner. The right to inspect and copy your medical information. This right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your records. The right to request an amendment of your medical information. We may deny your request for certain specific reasons, and, if denied, we will provide you with a written explanation for the denial and information regarding further rights you would have at that point. The right to receive an accounting of the disclosures of your medical information made by the Hospital in the six years prior to your request, except for disclosures for treatment, payment or Hospital operational purposes, and for certain other specific disclosure types. The right to request a paper copy of this Notice of Privacy Practices for Protected Health Information. The right to complain to the Hospital and/or to the United States Department of Health and Human Services if you believe that the Hospital has violated your privacy rights. To complain to the Hospital, please contact: The Administrative Department of the Hospital in question. If you choose to file a complaint you will not be retaliated against in any way. If you would like further information regarding your rights or regarding the uses and disclosures of your medical information, you may contact our administrator, Mr. Robert R. Lodes at: Mississippi Sports Medicine Clinic and Orthopaedic Center, PLLC 1325 East Fortification St. Jackson, MS 39202 Phone: 601-354-4488 Fax: 601-914-1849 THIS NOTICE IS EFFECTIVE AS OF 7/10/2008 Patient Acknowledgement of Receipt of Notice of Privacy Practices Patient Signature: Date: