List any past surgeries that you have had throughout your lifetime (if none, circle NONE):

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Aron Berry
6 years ago
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New Patient Mobility Intake Form NAME: DATE OF BIRTH: Address City State Zip Code Phone Gender Male Female Height Weight Social Security Number Email address Primary Insurance Group # -- Secondary

1 New Patient Mobility Intake Form NAME: DATE OF BIRTH: Address City State Zip Code Phone Gender Male Female Height Weight Social Security Number address Primary Insurance Group # -- Secondary Insurance ID # Who referred you for a mobility device? PRIMARY CARE PHYSICIAN: PCP phone: Check any past medical problems that you have been treated for: Arthritis Asthma Cancer Diabetes Seizures Headaches Hearing problems High blood pressure Heart disease Heart attack Kidney failure Muscle weakness Multiple sclerosis Spinal cord injury Stroke Neck pain Shoulder pain Elbow pain Hand/wrist pain Chest pain Back pain Hip pain Knee pain Ankle pain Pressure sore Location Stage Amputation location Other List any past surgeries that you have had throughout your lifetime (if none, circle NONE): Other sideè 1

2 Medications you are taking (if none, circle NONE): Name Dose Frequency Name Dose Frequency Allergies (if none, circle NKDA): Social history: Marital Status: Single Married Divorced Widowed Do you live alone or with someone? With whom? Do you smoke tobacco? Y N Have you smoked in the past? Y N For how many years? Do you drink alcohol? Y N How often? How much at one sitting? Do you use any street drugs? Y N Which drugs? 2

3 Family History: Mother Alive Deceased Does/did your mother have any medical problems? (Please list) Father Alive Deceased Does/did your father have any medical problems? (Please list) Review of systems: Have you experienced any of the symptoms below within the past 24 hours? Chills/fever Headaches Blurry vision Wear glasses/contacts Difficulty hearing Nasal discharge Cough Sore throat Difficulty swallowing Shortness of breath Gas/bloating Diarrhea Constipation Abdominal pain/cramping Urinary incontinence Bowel incontinence Difficulty walking Arm weakness Leg weakness Numbness/tingling Shooting pain Signature Print name Other sideè 3

4 Consent For Treatment I authorize and request my physician to carry out physical exams, treatment and/or diagnostic procedures now, or during the course of my treatment, as they become advisable. I understand the purpose of these procedures will be explained to me upon my request and that they are subject to my agreements. I also understand that while the course of my treatment is designed to be helpful, my physician can make no guarantees about the outcome of my treatment. I, the responsible party, authorize the release of any information necessary to process insurance claims. I further understand that my case may be discussed in consultation for the purpose of optimal patient care. Patient (Parent/Guardian) Signature Consent and Assignment of Benefits Optimal Medical & Rehabilitation (OMR) is contracted to various health insurance programs, including Medicare, and accepts assignments only for those health insurances. If a contract exists between my insurance company and Optimal Medical & Rehabilitation, OMR will file my health insurance. I request that payment be made by my insurance on my behalf to Optimal Medical & Rehabilitation. I agree to pay any portion of my charges rendered by Optimal Medical & Rehabilitation that my contracted health insurance determines is my responsibility. If I do not have a health insurance plan that Optimal Medical & Rehabilitation is contracted with, I agree to pay all fees in full at the time services are rendered. I understand that I am ultimately responsible for payment of my medical bill. If it becomes necessary for Optimal Medical & Rehabilitation to collect payment, I understand that I will be responsible for legal costs, including attorney s fees. I understand that as a result of refusal to sign this form, or if I have altered this form in any way, Optimal Medical & Rehabilitation may refuse to diagnose and treat me. I have the right to revoke this consent and assignment of benefits in writing except for services that have already occurred. By signing below, you acknowledge receipt of the Joint Notice of Privacy Practices for Medical Information and understand the Assignment of Benefits as the patient, the patient s personal representative, the patient s authorized agent or an individual involved in the patient s medical care. Patient (Parent/Guardian) Signature 4

5 Consent to use/disclose protected health information Before using or disclosing your protected health information to carry out treatment, payment, or healthcare operations, we are required under Federal law to obtain your consent. By signing this consent, you agree that we may use or disclose your protected health information to carry out treatment, payment, or healthcare operations. Our Notice of Privacy Practices (Notice) gives a complete description of the permissible uses and disclosures of your protected health information. Please note that we may change the privacy practices described in the Notice. If we change our Notice you may obtain a copy from the Operations Manager. You have the right to request that we restrict how your protected health information is used or disclosed to carry out treatment, payment or healthcare operations. We are not required to agree to such restrictions. However, if we agree to a restriction, such restriction will be binding. You have the right to revoke this consent by submitting a written notice to this office, except to the event that we have taken action in reliance on your consent. I have read this consent and do hereby acknowledge the receipt of The Notice of Privacy Practices. I have read and understand my rights. Patient signature (if applicable) /Time Notice Obtained Patient name Patient s guardian/representative Relationship to patient Other sideè 5

6 Patient Identification (print) Name Authorization For Receiving and Using Protected Health Information of birth Address Phone Agency Releasing PHI (print) Name Address Phone Fax Information to be released Covering the periods of Health Care From To Please check type of information to be released: History and physical exam Progress notes Laboratory test results Discharge summary Imaging (MRI/CT/Xray) Other Purpose of request: Treatment or consultation At the request of the patient Billing or claims payment Other Please send requested information to: Optimal Medical & Rehabilitation Fax: (702) Phone: (702) S. Rainbow Blvd, Suite 200, Las Vegas, NV Time limit and right to revoke authorization Except to the extent that action has already been taken in reliance on this authorization, at any time I can revoke this authorization by submitting a notice in writing to Optimal Medical & Rehabilitation Operations Manager at 1341 S. Rainbow Blvd, Suite 200, Las Vegas, NV Unless revoked, this authorization will expire 180 days from date of signature, unless otherwise specified. Re-disclosure I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer be protected by the Health Insurance Portability and Accountability Act of The facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. Signature of patient or personal representative who may request disclosure I understand that I do not have to sign this authorization and my treatment or payment for services will not be denied if I do not sign this form unless specified above under Purpose of Request. I can inspect or copy the protected health information to be used or disclosed. I authorize Optimal Medical & Rehabilitation to use and disclose the protected health information specified above. Patient signature Patient Guardian/Representative Relationship to patient 6

PRINT CLEARLY. Name: (first) (last) (m.i) Address: City: State: Zip:

PRINT CLEARLY. Name: (first) (last) (m.i) Address: City: State: Zip: PRINT CLEARLY NEW PATIENT FORM Name: (first) (last) (m.i) Address: City: State: Zip: Email: Sex: Male Female Student Yes No Home Ph: Cell Ph: Work Ph: Fax: Age: Of Birth: Statement Preference: E-mail Fax