Financial Policy GENDER: MALE FEMALE DOB: / / AGE: SINGLE MARRIED WIDOW

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Susanna Linette Pierce
5 years ago
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1 THE ORTHOPEDIC SURGEONS CLINIC An affiliate of Liberty Hospital Patient Information Patient FIRST, MIDDLE, LAST: Financial Policy GENDER: MALE FEMALE DOB: / / AGE: SINGLE MARRIED WIDOW ADDRESS: 1. Fees are due and payable at the time CITY: of your appointment. If we STATE: are contracted with ZIP: your insurance, HOME CELL: checks, Visa, Discover, and Master Card. PATIENT S 2. If EMPLOYER: you have an HMO or PPO insurance with a designated OCCUPATION: primary care physician, please make SOCIAL SECURITY BIRTH SEX EMPLOYER ADDRESS: SPOUSE NAME: card or information, you EMPLOYER: will be required to pay the entire fee OCCUPATION: including any lab services. EMPLOYER ADDRESS: 4. Not all services are a covered benefit in all contracts. If you have a question regarding benefits, EMERGENCY CONTACT (RELATIONSHIP): COUNTY insurance policy is a contract between RACE you and your insurance company. LANGUAGE ETHNICITY REASON FOR CONSULT: LEFT RIGHT BOTH (LIST BODY PARTS) 5. All services must be paid in full within 30 days after your insurance has paid their portion. If your visit is due to a Motor Vehicle Accident, payment in full is due at the time of the service. REFERRED BY: (FIRST AND OF PHYSICIAN OR HOSPITAL) FAMILY PHYSICIAN: not get involved in court decisions or support SEND disputes. RECORDS TO THIS PROVIDER? YES NO HOME MEDICAL PHONE 7. INSURANCE Accounts become INFORMATION past due (GIVE after INSURANCE 30 days. DAY We PHONE CARD reserve TO RECEPTIONIST) the right to send an account CELL PHONE to collections PRIMARY INSURANCE: ID#: GROUP# ALTERNATE ADDRESS: PHONE FOR EMERGENCY CO-PAY: $ POLICY 9. HOLDER: SSN#: / / DOB: SECONDARY 10. All deductibles INSURANCE: and co-payments for ID#: Obstetric (OB) services GROUP#: must be paid in full by the 7th month with regular payments due each month by cash, check or credit card. ADDRESS: CO-PAY: $ POLICY I hereby HOLDER: acknowledge that I have read, understand, SSN#: / and / agree to DOB: the terms of this document relating PATIENT to insurance IS A MINOR-PLEASE coverage and payment COMPLETE of my bill. PARENT/GUARDIAN: WORK: ADDRESS EMPLOYER: CITY PATIENT/GUARDIAN S PRINT PATIENT S NAME & BIRTH ADDRESS: PLAN WHO DOES THE MINOR LIVE WITH? POLICY Signature On File GROUP NAME I WORK authorize COMP use INFO of this form AUTO on all ACCIDENT my insurance GROUP INFO submissions. OTHER I authorize INJURY release INFO EFFECTIVE of information to OF all ACCIDENT: of my insurance companies. / / I authorize SUPERVISOR: direct payment to The Liberty Clinic. I permit a copy of BILLING ADDRESS: STATE: AGENT: charges whether or not INSURANCE: covered by insurance. CLAIM#: ADDRESS: Santosh George, M.D. Joshua J Niemann, M.D. Ryan R Snyder, M.D. Leslie D. Thomas, M.D. Brett L Wilson, PA-C Board Certified Diplomates of the American Board of Orthopaedic Surgery 2521 Glenn Hendren Drive, Suite 204, Liberty, Mo P F www. libertyhospital.org SSN# / / TOSC-009 1

2 PATIENT FULL LEGAL NAME OF BIRTH PATIENT PAST MEDICAL Allergies CHF (Conjestive Heart Failure) Immune system disorder Anemia COPD (Chronic Obstructive Pulmonary Disease) Irritable bowel disease Angina (chest pain) Coronary artery disease Liver disease Anxiety Asthma Arthritis Atrial fibrillation Benign Prostatic Hypertrophy Crohn s disease Depression Diabetes Gallbladder Disease Blood clots location GERD or chronic heartburn P.E./DVT When: Hepatitis A B C Blood clotting disorder Hyperlipidemia (high cholesterol) Cancer location Cerebrovascular accident (stroke) Hypertension (high blood pressure) Have you ever had General Anesthesia? Any complications? Yes No PATIENT PAST SURGICAL Fibromyalgia Malignant Hyperthermia Migraine headaches MRSA Myocardial infarction (heart attack) Osteoarthritis Osteoporosis Peptic ulcer disease Renal (kidney) disease Seizure disorder Thyroid high low other Angioplasty (heart cath) year Cataract extraction year Lasik year Angio (heart cath) w/stent year Gallbladder surgery year Liver biopsy year Appendectomy year Colectomy (colon resection) year ORIF (fracture repair) year Arthroscopy knee year Colostomy year Pacemaker year Back surgery year Gastric bypass, sleeve year CABG (heart bypass) year Hernia repair year Cardiac stents year Hip/Knee replacement year Carpal tunnel release year Any Hardware in body year Pacemaker/Difibrillator year Small bowel resection year Thyroidectomy year Tonsillectomy year Any Hardware in body yes no Type Location PATIENT PAST SURGICAL Women only Augmentation mammoplasty (implants) year D & C year Myomectomy (Fibroidectomy) year Bilateral tubal ligation year Hysterectomy (abdominal) year Reduction mammoplasty year Breast Biopsy year Hysterectomy (vaginal) year Oopherectomy (ovary removal) year Cesarean Section year Mastectomy year TAH/BSO year PATIENT/PARENT/GUARDIAN TOSC-009 2

3 Past Orthopedic History (please check all that apply): ANKLE FRACTURE OSTEOARTHRITIS SOFT TISSUE SARCOMA ANKYLOSING SPONDYLITIS OSTEOPENIA SPINAL STENOSIS, CERVICAL BURSITIS OSTEOPOROSIS SPINAL STENOSIS, LUMBAR DISH PRIMARY BONE SARCOMA VERTEBRAL BODY EPIDURAL INJECTIONS, SPINE PSORIATIC ARTHRITIS COMPRESSION FRACTURE RHEUMATOID ARTHRITIS FRACTURE VITAMIN D DEFICIENCY RICKETTS GOUT WRIST FRACTURE RSD HIP FRACTURE NONE SCIATICA Patient HNP, Financial CERVICAL Policy SCOLIOSIS OTHER HNP, LUMBAR SPINE FRACTURE METASTATIC BONE DISEASE Past Orthopedic checks, Visa, Surgery Discover, (please and Master check Card. all that apply): ACHILLES 2. If you TENDON have an REPAIR HMO or PPO insurance with a designated KNEE primary ARTHROSCOPY care physician, please make SOCIAL SECURITY BIRTH SEX ACL RECONSTRUCTION card or information, you will be required to pay the KYPHOPLASTY/VERTEBROPLASTY entire fee including any lab services. BILLING ADDRESS 3. RIGHT All co-pays STREET LEFT must be BOTH paid at the time of CITY your servicelumbar FUSION ANKLE 4. FRACTURE Not all services ORIFare a covered benefit in all contracts. LUMBAR If you have LAMINECTOMY a question regarding benefits, LUMBAR SPINE SURGERY: DECOMPRESSION COUNTY BUNION insurance CORRECTION policy is a contract between RACE you and your LUMBAR insurance SPINE company. LANGUAGE SURGERY: DECOMPRESSION ETHNICITY 5. RIGHT All services LEFT must be BOTH & FUSION paid in full within 30 days after your insurance has paid their portion. If your CARPAL visit TUNNEL is due DECOMPRESSION LUMBAR SPINE SURGERY: DISC REPLACEMENT to a Motor Vehicle Accident, payment in full is due at the time of the service. 6. RIGHT The person LEFT who brings BOTH MENISCUS REPAIR a child for care is ultimately responsible for their bill. The physician will CERVICAL not SPINE get involved SURGERY: in court ACDF decisions or support disputes. HOME CERVICAL PHONE 7. Accounts SPINE become SURGERY: past DISC due REPLACEMENT after 30 days. DAY We PHONE reserve REVERSE TOTAL SHOULDER the right to send an account CELL PHONE REPLACEMENT to collections DISTAL if RADIUS not paid ORIF in full 8. RIGHT All returned LEFT checks BOTH REVISION OF TOTAL KNEE ARTHROPLASTY must be paid with cash or money order within 5 working days or they will be GANGLION CYST EXCISION INTERMEDULLARY 9. NAILING FEMUR REVISION OF TOTAL SHOULDER ARTHROPLASTY 10. RIGHT All deductibles LEFT and BOTH co-payments for Obstetric (OB) services must be paid in full by the 7th month JOINT REPLACEMENT: with regular payments HIP ROTATOR CUFF REPAIR due each month by cash, check or credit card. JOINT I hereby REPLACEMENT: acknowledge KNEE SHOULDER ARTHROSCOPY that I have read, understand, and agree to the terms of this document relating to insurance RIGHT coverage LEFT BOTH and payment of my bill. JOINT REPLACEMENT: SHOULDER TRIGGER FINGER RELEASE ADDRESS LOCATION: CITY NONE PATIENT/GUARDIAN S PRINT PATIENT S NAME & BIRTH OTHER PLAN Social History: Signature On File POLICY CIGARETTE SMOKING ALCOHOL USE EXERCISE FREQUENCY GROUP NEVER NAME I authorize SMOKED use of this form on all my DO insurance NOT GROUP DRINK submissions. ALCOHOL I authorize release SEVERAL EFFECTIVE of information TIMES A to DAY QUIT: all of FORMER my insurance SMOKER companies. I authorize LESS THAN direct 1 payment DRINK A to DAY The Liberty Clinic. ONCE I permit A DAY a copy of SMOKES this authorization LESS THAN to DAILY be used in place 1-2 of the DRINKS original. A DAY I understand I am financially FEW responsible TIMES A WEEK for all SMOKES charges DAILY whether or not covered by insurance. 3 OR MORE DRINKS A DAY FEW TIMES A MONTH # PACKS PER DAY NEVER TOSC-009 2

4 Medications (please list all current medications or check the option that applies): I BROUGHT A COPY OF MY MEDICATION LIST (PLEASE PROVIDE TO THE RECEPTIONIST) NOT CURRENTLY TAKING ANY MEDICATIONS MEDICATION NAME DOSAGE # TIMES TAKEN PER DAY Patient Financial Policy checks, Visa, Discover, and Master Card. 2. If you have an HMO or PPO insurance with a designated primary care physician, please make SOCIAL SECURITY BIRTH SEX card or information, you will be required to pay the entire fee including any lab services. 4. Not all services are a covered benefit in all contracts. If you have a question regarding benefits, Allergies (please list all known allergies or check the option that applies): COUNTY insurance policy is a contract between RACE you and your insurance company. LANGUAGE ETHNICITY I BROUGHT 5. All services A COPY must OF be MY paid ALLERGY in full within LIST (PLEASE 30 days PROVIDE after your TO insurance THE RECEPTIONIST) has paid their portion. If your NO KNOWN visit is ALLERGIES due to a Motor Vehicle Accident, payment in full is due at the time of the service. ALLERGY not get involved TYPE in court decisions PLEASE or DESCRIBE support disputes. ALLERGIC REACTION SEVERITY AND SYMPTOMS HOME PHONE 7. Accounts become past due after 30 days. DAY We PHONE reserve the right to send an account CELL PHONE to collections All deductibles and co-payments for Obstetric (OB) services must be paid in full by the 7th month with regular payments due each month by cash, check or credit card. Family History (please inform us of family members medical history by marking the appropriate box): I hereby acknowledge that I have read, understand, and agree to the terms of this document relating to insurance coverage and payment of my bill. ADDRESS CITY HYPERTENSION PATIENT/GUARDIAN S PRINT PATIENT S NAME & BIRTH OSTEOARTHRITIS PLAN POLICY OSTEOPOROSIS Signature On File SCOLIOSIS MOTHER FATHER SISTER BROTHER DAUGHTER SON OTHER GROUP NAME I authorize use of this form on all my insurance GROUP submissions. I authorize release EFFECTIVE of information to DIABETES all of my TYPE insurance 2 companies. I authorize direct payment to The Liberty Clinic. I permit a copy of OTHER charges whether or not covered by insurance. NO FAMILY HISTORY (INDICATED NO PAST FAMILY MEDICAL HISTORY) TOSC-009 3

5 Review of Systems* (check yes or no if you currently are experiencing any of the following): SYMPTOM YES NO Patient Financial Policy UNSTEADY GAIT NUMBNESS checks, Visa, TINGLING Discover, and Master Card. 2. If you have UNEXPECTED an HMO or PPO WEIGHT insurance LOSS with a designated primary care physician, please make SOCIAL SECURITY BIRTH SEX FEVER card or information, you will be required to pay the entire fee including any lab services. CHILLS 4. Not all services POOR are HEALING a covered benefit WOUNDS in all contracts. If you have a question regarding benefits, SCARRING / KELOIDS COUNTY insurance policy RACE LANGUAGE ETHNICITY EASY is BLEEDING a contract between you and your insurance company. 5. All services must be paid in full within 30 days after your insurance has paid their portion. If your visit is due to a Motor Vehicle Accident, payment in full is due at the time of the service. Alerts* not get involved in court decisions or support disputes. HOME PHONE (check 7. Accounts yes or become no for past the due following): after 30 days. DAY We PHONE reserve the right to send an account CELL PHONE to collections ALERT YES NO PACEMAKER All deductibles BLOOD and co-payments THINNER for Obstetric (OB) services must be paid in full by the 7th month with regular DEFIBRILLATOR payments due each month by cash, check or credit card. PREMEDICATION PRIOR I hereby acknowledge TO that PROCEDURES I have read, understand, and agree to the terms of this document relating to insurance coverage RHEUMATOID and payment ARTHRITIS of my bill. RSD (REFLEX SYMPATHETIC DYSTROPHY) ADDRESS CITY ALLERGY TO SHELLFISH PATIENT/GUARDIAN S PRINT PATIENT S NAME & BIRTH OR IODINE PLAN JOINT PAINS JOINT SWELLING JOINT STIFFNESS ALLERGY TO LATEX Signature On File ALLERGY TO ADHESIVE POLICY GROUP NAME I authorize use PAIN of this MANAGEMENT form on all my insurance TREATMENT GROUP submissions. I authorize release EFFECTIVE of information to all of my insurance companies. I authorize direct payment to The Liberty Clinic. I permit a copy of *Please charges inform whether the or physician, not covered medical by insurance. assistant or front desk staff of any other medical conditions or concerns. TOSC-009 4

New Child Registration

New Child Registration Date: / / Insurance Information Primary insurance Primary Reason for today s visit: Last Name, First, MI Mailing address City, State, ZIP Which pharmacy do you use? Insurance Co.