Orthopedics and Sports Medicine, LLC PATIENT INFORMATION SHEET

Transcription

1 Orthopedics and Sports Medicine, LLC PATIENT INFORMATION SHEET NAME DATE NAME OF PARENT/LEGAL GUARDIAN (IF PATIENT IS A MINOR) ADDRESS CITY STATE ZIP CODE HOME PHONE CELL PHONE DATE OF BIRTH AGE MARITAL STATUS SOCIAL SECURITY# ADDRESS OK TO CONTACT VIA ? Y N EMERGENCY CONTACT PHONE REFERRING PHYSICIAN PHONE PATIENT S EMPLOYER CITY WORK PHONE ARE YOU A STUDENT? PRIMARY INSURANCE I.D. NUMBER Group # POLICY HOLDER DATE OF BIRTH RELATION SECONDARY INSURANCE I.D. NUMBER Group # POLICY HOLDER DATE OF BIRTH RELATION PHARMACY INFORMATION (ALL RX S ARE ELECTRONICALLY SENT TO YOUR PHARMACY) NAME: STREET ADDRESS: PHONE NUMBER:

2 Orthopaedics & Sports Medicine, LLC MEDICAL INFORMATION SHEET Patient Name: Age: Date of Visit: Female Male Weight Height Right Handed Left Handed PRIMARY CARE PHYSICIAN S NAME/PHONE: Present Complaint: When/how did this injury occur: Was it related to a motor vehicle or work related injury FOR PHYSICIAN USE ONLY HISTORY OF PRESENT ILLNESS (These are preliminary notes refer to dictation for more details) USING THE SYMBOLS BELOW, PLEASE DRAW IN THE LOCATION OF YOUR SYMPTOMS X = Pain O = Numbness / = Aching * = Pins and Needles If you have NECK PAIN, what percentage is % Neck and % Arm (Total 100%) If you have BACK PAIN, what percentage is % Back and % Leg (Total 100%) Please indicate on the scale below your level of pain. (0 meaning no pain, 10 being the worst) Least Worst Please put an X in the box if the positions make your pain Better or Worse Worse Better Comments Bending Bowel movement Coughing General Activity Home Remedies Lying down Sitting Standing Walking

3 PATIENT S NAME How long can you STAND with no or minimal pain minutes WALKING DISTANCE with no or minimal pain ft ft ft 500+ ft 1/2 mile + Do you need SUPPORT to help you walk? Yes No If yes, what kind of support? Do you wear a back or neck BRACE? Yes No If yes, what kind of brace? List below the PREVIOUS PHYSICIANS (MD, DO, Chiropractor) you have seen for your main complaint. Physician Specialty Dates Treatment Past Medical History Please check all that apply: Asthma Blood Clots Osteoporosis Recurrent Infections Ulcers Gout Bleeding Disorder Stroke Thyroid Disease Cancer Type Diabetes High Cholesterol Heart Disease Circulation Problems Pacemaker Kidney Disease Hypertension Rheumatism Other Hepatitis HIV/Aids PAST SURGICAL HISTORY Type Date Outcome Do you have any allergies? Antibiotics/Mediations Surgical Tape Iodine/Shellfish Local or general Anesthesia Seasonal allergies Other CURRENT MEDICATIONS/DOSE

4 PATIENT S NAME SOCIAL HISTORY: Occupation: Marital Status Education Level Work Status: Full Duty Light Duty Off Duty per Physician Unemployed Retired If you are NOT working full duty: How Long Have you had a work capacity assessment Yes No Are you disabled through Social Security Yes No Tobacco Use: Yes No Cigarettes Cigars Chewing Tobacco (snuff) Started Age/Year Stopped Quantity per day: Alcohol Use: Do you consume alcoholic beverages Yes No Beer Wine Distilled Spirits Quantity per day: Have you ever been treated for drug or alcohol addiction? Yes No SIGNIFICANT FAMILY HISTORY REVIEW OF SYSTEMS: CONSTITUTIONAL EYES/EAR/NOSE/THROAT RESPIRATORY Weight gain last 6 months Recent changes in vision Short of breath Weight loss last 6 months Recent changes in hearing Cough Night Sweats Recent changes in smell Sputum Chills Recent changes in taste History of tuberculosis Fever Dizziness Wheezing GASTRONINTESTINAL GENITO-URINARY CENTRAL NERVOUS Nausea Blood in urine Poor Appetite Vomiting Urinary tract infection Problem sleeping Dairrhea Unable to control bladder Numbness/tingling feet Indigestion Unable to control bowel Numbness/tingling hands Abdominal pain Rushing to go Crying spells Bloody/dark stools Need to go frequently Convulsions CARDIOVASCULAR MUSCULOSKELETAL SKIN Chest pain Cramps Easy bleeding Palpitations Attack of weakness Any rashes Shortness of breath w/exercise Joint pain/swelling Easy bruising Heart murmur Morning stiffness Feet edema Who referred you to our practice? Patient Primary Care Physician Another Physician Insurance Plan Online Directory Patient s Signature Physician s Signatue

5 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among multiple healthcare providers that may be involved in my treatment directly and/or indirectly. Obtain payment from third party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read and understand your Notice or Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice from time to time and that I may contact them at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may also request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree you are bound to abide by such restrictions. I understand that request to forward my medical records to another treating physician other than my primary care physician must be made in writing. Patient Name: Signature: Date: I hereby give permission for the following to obtain any medical information on my behalf: Name Relation: Name: Relation:

6 ASSIGNMENT OF BENEFITS I irrevocably assign to you, my medical provider, all of my rights and benefits under my insurance contract for payment for services rendered to me. I authorize you to file insurance claims on my behalf for services rendered to me and this specifically includes filing arbitration/litigation in your name on my behalf against the PIP carrier/health care carrier. I irrevocably authorize you to retain an attorney of your choice on my behalf for collection of your bills. I direct that all reimbursable medical payments go directly to you, my medical provider. I authorize and consent to your acting on my behalf in this regard and in regard to my general health insurance coverage pursuant to the benefit denial appeals process as set forth in the NJ Administrative Code. In the event the insurance carrier responsible for making medical payments in this matter does not accept my assignment, or my assignment is challenged or deemed invalid, I execute this limited/special power of attorney and appoint and authorize your collection attorney as my agent and attorney to collect payment for your medical services directly against the carrier in this case, in my name, including filing an arbitration demand or lawsuit. I specifically authorize that attorney to file directly against that carrier in my name or in your name as a medical provider rendering services to me and designate your collection attorney as my attorney in fact. I further grant limited power of attorney to you as my medical provider to receive and collect directly from the insurance carrier money due you for services rendered to me in this matter, and hereby instruct the insurance carrier to pay you directly any monies due you for medical services you rendered to me. I authorize you and or your attorney to receive from my insurer, immediately upon verbal request, all information regarding last payment made by said insurer on my claim, including date of payment and balance of benefits remaining. I authorize you and or your attorney to obtain medical information regarding my physical condition from any other health care provider, including hospitals, diagnostic centers, etc., and I specifically authorize such health care provider(s) to release all such information to you about me, including medical reports, X-ray reports, narrative reports, and any other report or information regarding my physical condition. I authorize Active Orthopedics and Sports Medicine, LLC to furnish my records of medical history for services rendered or treatment given to me for the purpose of review of filing a claim with my insurance carrier. If applicable, I also request payment of government benefits to the part who accepts assignment. I understand that I am responsible for all deductibles, co-insurance, co-payments or any portion of the bill that my insurance company does not approve/deny. I understand that if required, a valid referral is due at the time of services; otherwise my appointment will be rescheduled. Dated: Patient s Signature Patient s Signature

7 ACKNOWLEDGEMENT OF FEE FOR REQUESTED XRAY COPIES Please be advised that there is a fee for all X-Rays that are released from Active Orthopedics and Sports Medicine, LLC, at your request. X-rays are the sole property of the practice and must be maintained on site as part of your legal medical records for seven years. Hackensack Office: All films are now digitally acquired and stored on a computer. They can be copied to a CD on the same day of service for $5.00. We do require a 24 hour notice to retrieve and scan old films to a CD if seen prior to August 30,2011. Emerson Office: If you wish to have your X-rays copied to CD for $5.00 we require a 5 day notice required to bring your films to Hackensack for scanning and then back to Westwood for pick-up OR you can have copies within 24 hours for the following charges: Thank you. Active Orthopedics and Sports Medicine, LLC Patient Name Signature Date: