Montville MedSpa & Pain Center

Transcription

1 New Patient Registration First Name: Last Name: Middle Initial: Address: Date of Birth: Social Security Number: Home Phone: Cell Phone: Work Phone: Address: Sex: Male Female Marital Status: Single Married Separated Divorced Widowed Ethnicity: Hispanic Non Hispanic Other Preferred Language: English Spanish Other (please indicate): Race: Caucasian African American Asian Hawaiian Pacific Islander Other Primary Care Physician/Contact #: Referred by: Pharmacy Name: Pharmacy Phone Number: Employer: Please provide an EMERGENCY CONTACT: Name: Home Phone: Cell Phone: Relationship to Patient:

2 Section 2: Patient History What is your age? What is your main pain complaint? If pain is located in the neck or back, does it radiate into your arms or legs? Yes No How long has this pain been present? (Indicate number of months or years) Months Years Is the pain associated with any other symptoms? None Difficulty walking Numbness, where Weakness, where Sexual dysfunction Other What words best describe how the pain feels? Sharp Burning Shooting Deep Stabbing Throbbing Aching Pressure Dull Tingling Other How often is the pain present? Constant Frequent (several times per hour) Sporadic (several times per day) Occasional (several times per week) Rare (several times per month) Please shade the areas where you are having pain For the scales below, circle a number using 0 to indicate none up to 10 to indicate most extreme/severe Please indicate your current pain Please rate your worst pain in the last week Please rate your least pain in the last week What makes your pain better? Rest Heat Cold Medication Exercise Other What makes your pain worse? Heat Cold Walking Bending/Twisting Sitting Standing Lying Stress Coughing/Sneezing Standing from sitting Since your pain began, have you experienced any of the following? Bowel incontinence Bladder incontinence Neither Has the pain affected your sleep? Yes No Pain History Is this a workmen s compensation injury? YES / NO If YES, please explain what happened and when:

3 Motor Vehicle accident Date: Fall or other trauma Date: Following surgery Date: Following illness Date: Unknown reason Other What diagnosis, if any, have you been given for your current pain? How did your main pain complaint begin? Treatment History Have you ever been treated by another pain management physician or clinic? Yes No Name of physician/clinic Location Dates of treatment Reason for leaving Name of physician/clinic Location Dates of treatment Reason for leaving Have you had surgery intended to treat your current pain complaint? Yes No Surgery #1 Procedure name Date Surgeon Surgery #2 Procedure name Date Surgeon Have you seen any other specialists related to your main pain complaint (Including Physical Therapy, Chiropractic care, acupuncture)? No Yes Name of specialist Specialty Date seen Name of specialist Specialty Date seen Have you had an Electromyography or EMG test to evaluate nerve function? Yes No Performed on arms/legs/both? Physician performing test Date Performed on arms/legs/both? Physician performing test Date Have you had Radiologic Imaging for your current pain complaint? Yes No Please bring actual films or CD containing the images to your initial appointment Study type Body part imaged Date of study Where study was performed

4 X-ray MRI CT Ultrasound Past Medical History Have you been diagnosed with any of the following conditions at any point in your life? Abnormal heart beat Depression Heart Attack Rheumatoid Arthritis Stomach ulcer or GI bleed Anxiety Emphysema/COPD Osteoarthritis Heartburn/Acid Reflux Insomnia Cancer Peripheral Neuropathy Diabetes Seizures Stroke Multiple Sclerosis (MS) Liver Disease Fibromyalgia Asthma Irritable bowel Kidney Disease Migraine Headaches Hypothyroid/Hyperthyroid HIV/AIDS Bleeding Disorder Psychiatric Conditions High Blood Pressure Vascular disease Sleep Apnea Alcoholism Hepatitis Broken Bones Other conditions not listed above: Past Surgical History Surgery Date (month/year) Surgeon Current Medications

5 ` Allergies Do you have any known allergies? Yes No Are you allergic to shellfish? Yes No If yes, please list your allergies below Are you allergic to IV contrast dye? Yes No Family History Are you allergic to local Yes No Anesthetics? Are you allergic to latex? Yes No Please list medical problems of your immediate family such as diabetes, high blood pressure, cancer, heart disease, etc. Relation Medical Condition Relation Medical Condition Father Sister Mother Brother Social History Occupation: Do you use tobacco? Never Occasional Former smoker YES! Cigarettes packs/day Cigars /day Do you drink Alcohol: Yes No If Yes, how often Review of Systems:

6 Constitutional Weight Gain Weight Loss Difficulty Sleeping Fever Fatigue Eyes Blurred Vision Double Vision Eye Pain Redness and Drainage Excessive Watering Ear, Nose, Throat Nosebleeds Snoring Hearing Loss Ringing in Ears Dizziness Cardiovascular Chest Pain/Pressure Irregular Heart Rate Rapid Heart Rate Swelling in Legs/Feet Poor Circulation Respiratory Chronic Cough Wheezing Shortness of Breath Coughing up blood Home Oxygen Use Gastrointestinal Constipation Diarrhea Nausea/Vomiting Blood in Stool Abdominal Pain Genitourinary Frequent Urination Incontinence of Urine Painful Urination Blood in Urine Kidney Stone Musculoskeletal Joint Pain Stiffness of Joints Joint Stiffness Muscle Spasms/Cramps Muscle Weakness Dermatologic Easy Bruising Itching Color Change Rashes Nail or Hair Change Neurological Fainting Headache Poor Memory Recent Falls Seizures Psychiatric Excessive Worry Frequent Sadness Depression Feeling Hopeless Excessive Stress Endocrine Heat Intolerance Cold Intolerance Changes in Appetite Abnormal Sweating Hair Loss

7 INSURANCE INFORMATION Medical Insurance: Primary Insurance Carrier: ID #: Group #: Secondary Insurance Carrier: ID #: Group #: Responsible Party: Patient Other (if other, please complete fields below) If this visit is related to work or accident provide MVA/WC Insurance information: First Name: Last Name: Middle Initial Address: Home Phone: Cell Phone: Select Accident Type: Motor Vehicle Worker s Compensation Insurance Carrier: Policy Number: Date of Accident: Claim Number: Full Claim Address: Adjuster/Case Manager Information (If Applicable): Name: Phone: Fax: Attorney Information (If Applicable): Name: Phone: Fax:

8 CONSENT FOR COMMUNICATIONS I request that all communications to me by and/or its staff be handled in the following manner: Address for Written Communication: Select if same as address above For Oral Communication: Please circle preferred method (based on phone numbers provided above): Home/Cell/Work I give my permission for Montville PRC to leave a message on my machine. Yes No Patient Signature: Date: Patient Name Printed:

9 FINANCIAL POLICY Please read and sign Thank you for choosing us as your health care providers. The health care industry is rapidly evolving and with the constant changes in insurance policies and the growing costs of maintaining quality health care services, we have implemented the following financial policy which we ask that you read, accept and acknowledge. REGARDING COMMERCIAL INSURANCES: We must have a copy of your current insurance card. Therefore, it is the responsibility of the patient to make sure you offer your insurance card to the Receptionist for copying if your insurance has changed since your last visit. If you have a co-pay on your card, you will be responsible for the payment of that co-pay on the day of your appointment. All co-pays are collected upon arrival. If your insurance has lapsed in coverage, or is not in effect at the time of service, You will be responsible for payment of services REGARDING MEDICARE PATIENTS: Patients are responsible for meeting their annual deductible each year. Once the deductible has been met, patients without secondary insurance will be required to pay their 20% portion at the time of their visit. If you have secondary/supplementary insurance it is the responsibility of the patient to provide our staff with a copy of that card. We will file with secondary/supplementary carriers; however, in the event that the secondary insurance does not pay, patients will be billed for the balance. REGARDING MOTOR VEHICLE ACCIDENT (MVA) PATIENTS: Patients are responsible for meeting the deductible on their motor vehicle insurance policy If you have supplementary insurance it is your responsibility to provide our office with that information. If necessary, we will bill your supplementary insurance for costs that your MVA insurance does not pay for. In the event that the supplementary insurance does not pay, patients may be billed for the balance unless alternate payment method has been agreed upon between our office and the patient or the attorney involved. NON-PARTICIPATING INSURANCES AND SELF-PAY PATIENTS: If you have presented us with a health insurance card with which we do not participate, you will be expected to pay 100% of our billed amount at the time the services are rendered. PARTIAL PAYMENTS/PAYMENT PLANS: Partial payments will only be accepted if prior arrangements have been made. If you wish to proceed with any necessary testing and would like to set up a payment plan, this can be arranged with our staff. Payment plans can only be set up with credit or debit card information. Once a payment plan is arranged, payments must be made consistently or the balance will be considered delinquent. You may be subject to finance charges or eventually turned over to our collection agency. DELINQUENT ACCOUNTS: Delinquent accounts will be subject to monthly billing charges until the account is settled in full. OUR CANCELLATION POLICY: There will be will be a $25.00 charge for all no show appointments and a $50.00 charge for all no-show procedures. INSURANCE AUTHORIZATION AND ASSIGNMENT: (FOR ALL PATIENTS) I request payment of Medicare and / or participating managed care products be made payable to on my behalf for any services provided to me by this Practice. I authorize the release of any information about me to Medicare and / or other participating managed care products and its agents that may be needed to determine these benefits. FINANCIAL RESPONSIBILITY FOR PAYMENT I am aware that due to any of the reasons listed below, it may be possible that my insurance carrier will deny payment for services rendered to me today. In that event, I understand that I will be financially responsible for those charges. I do not have my insurance card with me This office does not participate with my insurance carrier I do not have health insurance and will pay for my visit today I have read the above Financial Policy and understand and agree with its terms. Patient name Printed: Patient Signature: Date:

10 HIPAA COMPLIANCE AND PRIVACY POLICIES Our office is fully committed to compliance with HIPPA guidelines by: 1. Providing appropriate security for our patient records 2. Protecting the privacy of our patient s medical information 3. Providing our patient with proper access to their medical records 4. Appropriately maintaining our patient information and billing processes in compliance with national standards I have read and understood the terms of the HIPAA. I have been advised of the details of the HIPAA Omnibus Notice of Privacy Practices and am acknowledging my right to obtain a copy of this document at any time that I choose. Patient name Printed: Patient Signature: Date: Patient Protected Health Information Disclosure Authorization Listed below are the names of the individuals with whom the physicians of have my permission to disclose and discuss my protected health information with. Any information that relates to my past, present or future physical/mental health or condition and other related healthcare services may be discussed. I understand that his authorization will remain in effect until I make a written request to change it. 1. Name: Relationship: 2. Name: Relationship: Patient Consent for Use and Disclosure Of Protected Health Information: Medication History I hereby give my consent for to obtain my medication history to carry out treatment and provide me with healthcare services. With this consent, may call my home or other alternative locations like the pharmacy or other physician s office or electronically from my health plan information regarding my medication history. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. Print Name: Patient Signature: Date:

11 Authorization of Record Release Patient Name: DOB: I, authorize the release of all medical records to at the address below. I Understand that all medical information includes all of my medical information, includes reference to drug and/ or alcohol abuse, psychiatric, social service, hepatitis B and C testing/treatment and/or sensitive information. I understand that this release is valid when I sign it and I may withdraw my consent to this release at any time either orally or in writing. Patient name Printed: Patient Signature: Date: