NEW PATIENT INFORMATION

Transcription

1 NEW PATIENT INFORMATION NAME: AGE: DATE: Referring Medical Provider: Self Referral: (if so, circle) Primary Care Physician: Are you: Male Female Right handed Left handed Ambidextrous CHIEF COMPLAINT Reason for visit/primary symptom: Location of your pain: Briefly describe your current symptoms: Does your pain refer to any other areas of your body? (describe) When did your symptoms begin? : How did your symptoms begin?: Circle the number that corresponds to the severity of your pain on a scale of means no pain and 10 is the worst pain you can imagine. At its worst: At its best: Average: Today: Which of the following best describes the character of your pain: Timing: Constant Intermittent Fluctuating Aching Quality: Throbbing Burning Superficial Deep Associated Symptoms: Tingling/numbness Where? Weakness Where? What makes your pain worse? What makes your pain better? What activities of daily life do your symptoms interfere with?: How long/far can you: Sit Stand Walk Have you ever had similar symptoms/injury before? Yes No Have you had any loss of bowel or bladder control? YES NO 1

2 PREVIOUS TREATMENT Have you had treatment since your pain began? Yes No Have you had any of the following tests or procedures?: Injections? Epidurals Facet Injections Radiofrequency Neurolysis EMG? Yes No Other treatments: Medical: Dr. Diagnosis given: Medications given Other treatment provided Physical Therapy: Yes No Therapist Date of 1 st visit Last visit Has it helped? Yes No Home exercise program given? No Yes Chiropractic: Yes No Dr. Date of 1 st visit Last visit Has it helped? Yes No PAST MEDICAL HISTORY Diabetes Lung Disease Anxiety Stroke Alcoholism Hypertension Asthma Depression Parkinson s Hepatitis High Cholesterol Ulcers/PUD Claustrophobia Polio Liver disease Heart Attack Hyperthyroidism Chronic pain Gout HIV/AIDS Glaucoma Hypothyroidism Cancer (type?): Heart Murmur Other PAST SURGICAL HISTORY Have you had any surgeries? Yes No If yes, please list type of surgery and approximate date: CURRENT MEDICATIONS: NAME DOSAGE HOW OFTEN PER DAY? MEDICATION ALLERGIES Yes No If yes, please list: Name Reaction Are you allergic or had any reaction to iodine, shellfish, IVP dye, or contrast media? YES NO 2

3 SOCIAL HISTORY Single Married Divorced Widowed Living together Separated Number of children: Ages: Do you smoke? Yes No How much? Previous Smoker? Yes No When stopped? Do you drink alcohol? Yes No How much? Do you use recreational drugs? Yes No What type/how often? Are you currently employed? Yes No If yes, type of job SLEEP HISTORY Does it take you longer than 30 minutes to fall asleep? Does pain disrupt your sleep? Yes No Yes No FAMILY HISTORY Please check box for any medical condition that a blood relative has a history of: Diabetes Lung Disease Anxiety Stroke Alcoholism Hypertension Asthma Depression Parkinson s Hepatitis High Cholesterol Stomach Ulcers Heart Attack Thyroid Disease Chronic pain Cancer Arthritis Other REVIEW OF SYSTEMS: Please mark those items which you CURRENTLY EXPERIENCE: GENERAL Fever Weight loss Weight gain Fatigue Chills Weakness DERMATOLOGIC Jaundice Itching Rash Lesions Easy bruising HEAD/HEARING& VISION Trauma Headaches Dizziness Blurry vision Blindness Changes/loss Double vision PULMONARY Shortness of breath Wheezing Cough Coughing up blood CARDIOVASCULAR Chest pain Leg swelling Racing heart GASTROINTESTINAL Abdominal pain Bloody stool Nausea Vomiting Diarrhea Black, tarry stool Incontinence of bowels Heartburn Constipation GENITOURINARY Pregnant (currently) Pain/burning on urination Painful menstruation Blood in urine Incontinence Venereal disease Urgency/frequency with urination MUSCULOSKELETAL Joint pain Joint swelling NEUROLOGICAL Numbness Tingling Pain with light touch PSYCHOLOGICAL Sadness Anxiety Depression 3

4 Mark on the areas on your body where you feel the described sensations. Use the symbols listed. Mark areas of radiating pain or numbness as well. Include all affected areas. Numbness Tingling Burning Stabbing/Sharp Aching Cramping NNN TTT BBB SSS AAA CCC R L L R R L L R R L L R 4

5 DATE: PRIMARY LANGUAGE SPOKEN: PATIENT NAME: Nick Name: (Last) (First) (Middle) CHECK ONE: SEX: M F CHECK ONE: MARRIED SINGLE WIDOWED DIVORCED RACE: DATE OF BIRTH: SOCIAL SECURITY: PATIENT S LOCAL ADDRESS: (Street) (City) (Zip) PERMANENT ADDRESS (IF DIFFERENT): HOME TELEPHONE #: ( ) CELL #: ( ) EMPLOYED BY: OCCUPATION: WORK # ( ) Work ADDRESS: EMERGENCY CONTACT: RELATIONSHIP: PHONE #: ( ) PRIMARY PHARMACY: PHONE #: ( ) LOCATION: PRIMARY CARE PHYSICIAN: CHECK ONE: ILLNESS/INJURY RELATED TO: WORK AUTO OTHER DATE OF INCIDENT: **Failure to disclose all insurance information could result in patient being responsible for balance** 5

6 INSURANCE INFORMATION NAME OF PRIMARY INSURANCE COMPANY: HMO PPO POS If WC or Personal Injury Adjuster Name and Phone: POLICY/ID# NAME OF SECONDARY INSURANCE COMPANY: HMO PPO POS POLICY/ID# ADDITIONAL INSURANCE COMPANY: HMO PPO POS POLICY/ID# *PLEASE GIVE FRONT DESK ALL INSURANCE CARDS AND DRIVERS LICENSE 6

7 Redding Spine & Sports Medicine Financial & Office Policies Authorization for Medical Release of Information: A form is attached in which you may allow family members and friends access to your medical information. Please fill this out if you would like anyone to have access to your information or participate in your care. Consent for Medical Treatment: I hereby authorize Redding Spine and Sports Medicine and all persons acting as agents thereof, as well as all medical personnel to whom I am referred, to furnish all forms of reasonable diagnostic, preventive, therapeutic and medical treatment to me. Signature Missed Appointments: Our office will try to do reminder calls as a courtesy but patients are ultimately responsible for keeping an appointment. 24 hours notice is required to reschedule or cancel a scheduled appointment. Our office receives referrals for many more patients than we are able to accommodate and we keep a waiting list of patients who are trying to be seen sooner. Please be advised that it is our office policy to no longer see patients who repeatedly miss scheduled appointments. A missed appointment fee of $50 may be applied (if allowed by your insurance carrier) if an appointment is missed after one warning is given. We understand unusual circumstances may arise. In order for our physicians to see patients in a timely manner your help in arriving promptly for your appointment is required. If you are late, our office may reschedule your appointment to a new date and time. We understand your time is valuable and will do our best to see you in a timely manner. Please be aware that sometimes certain situations and emergencies can occur and cause your provider to run late. Please be patient in these circumstances. Payment and Insurance Policy: Payment is expected at time of service. Your co-pay, coinsurance, and/or deductible is due upon arrival for your visit. For your convenience we accept checks, cash, Visa, MasterCard or American Express as forms of payment. You will be responsible for payment of any remaining balances after insurance is billed. We will require a scan of your insurance card and we will bill your insurance company for you. For those plans that are not contracted with our office we will submit claims to your carrier as a courtesy. Any deductible, coinsurance or non-covered services will be your responsibility. Monthly statements will be sent to collect those balances. Please inform our staff immediately of any insurance, address or phone number changes. 7

8 Non-Covered Service Policy: Certain services performed by our office are NOT COVERED by all insurance plans. We suggest you contact your insurance carrier to verify your benefits and understand when any non-covered services will be your financial responsibility as payment will be required prior to your appointment. Our office will try to notify you of a non-covered service if we are aware. Medicare requires a signature on an Advanced Beneficiary Notice [ABN] for non-covered services. Delinquent Accounts Policy: Delinquent accounts may be reported to our collection agency following normal collection procedures. If an account is reported to our collection agency a collection fee of 25% will be added to any outstanding balance. If a balance is over 61 days late, a 1.5% monthly interest fee will be added to the outstanding balance. Please inform our billing staff if you know your payment will be late in arriving or if payment arrangements are needed. Our office charges a $25.00 fee for all accounts closed, stop payments or checks returned for non-sufficient funds. Medical Records/Forms: Should you request a copy of your medical records, please allow our office 7-10 business days for completion. There may be a fee for obtaining them, depending on the volume of medical records requested. The fee for medical records is.25 per page for anything beyond 10 pages. Should you request our office to complete forms on your behalf for disability, work status, jury duty, FMLA, etc., there will be a charge of $25.00 per form. Payment of this charge is expected at time of completion. Referrals & Authorizations: If a referral is required by your insurance carrier you will be asked to obtain the referral prior to your appointment. If no referral exists on file or your referral has not been received, your appointment may be cancelled. Our office will obtain authorization for your procedure prior to scheduling your appointment. We suggest you contact your insurance carrier to verify your coverage, benefits and preauthorization requirements prior to having any procedures performed. Claims are paid based on medical necessity. Please be aware authorizations and referrals are not a guarantee of payment. Worker s Compensation: Our office will require you to inform us of any changes regarding your workers compensation claim. The following information is required: Adjustors Name, claim status, (litigation, supportive care, claim closed, new injury), DOI, carrier, claim number and claims address. Please have this information available prior to your appointment time. 8

9 Please sign below to verify that you have reviewed and will follow the above office policies: (Patient/Guarantor Printed Name) (Patient/Guarantor Signature) Date Acknowledgment of Receipt of Privacy Notice I acknowledge that I have been offered and/or received a copy of the office s Notice of the Privacy Practices. This handout will be available at the time of your office visit if you have received your paperwork by mail or online. Patient or legally authorized individual signature Date Printed Name if signed on behalf of the patient Relationship to patient Date 9

10 Personal Representative Authorization For Medical Release Form I authorize this facility to speak to the following family members or my personal representative regarding: apple All medical information, including but not limited to records pertaining to examinations, treatments, consultations, billing records, radiological studies and reports, history, physical findings, laboratory findings, admissions and discharge reports, diagnosis, prognosis and records, nursing and physicians notes and any other non-medical information in my file. apple Only the following types of information: The above medical information may only be released to the following persons: Family member/representative name Relationship I understand that I may terminate this medical authorization form. I must notify this facility in writing regarding termination and effective date. This authorization to remain valid (check one) apple Until revoked in writing apple Until, 20 I know that I am entitled to receive a copy of this agreement Name Signature Signed this day of, 20 10

11 Dear Patient, Should you have any billing related questions regarding your visit today, or future visits, please feel free to call your dedicated billing team at Pro Rev Medical. We are here Monday-Friday 7:00am-4:00pm to assist with questions regarding your account with Redding Spine and Sports Medicine. 1. Make a Credit Card Payment over the phone 2. Set up a payment plan 3. Questions/Disputes regarding your balance 4. Changes or updates to insurance information (877) Toll Free (530) Local Payments via check should be mailed to: P.O. Box Redding, CA Trish Scott-Billing Supervisor Inez Sandoval Billing/Patient Account Rep 11