Riverview Orthopedics and Sports Medicine 493 Westfield Rd

Transcription

1 Dear New Patient, Riverview Orthopedics and Sports Medicine 493 Westfield Rd Noblesville, IN (317) (Fax: ) Tipton: Thank you for choosing our practice for your orthopedic care. Maps and further information about our practice are located on our website: Jeffrey R. Ginther, MD Our office is located at Riverview 493 Westfield Road Hospital in Building 493 in Noblesville, IN. Suite A This office is conveniently located on the hospital Noblesville, IN complex directly behind the hospital (south of the emergency room) The informational forms that follow are needed by our office to insure the best care and most efficient processing of your bill. Please pay particular attention to the medical history form so that it can be as complete and accurate as possible. We have provided these forms prior to your visit as we realize it is difficult to remember these important details in the few minutes prior to your appointment. We will ask you to update your medical information periodically, but please be sure to notify us of additions and changes to your medical history. We recommend that you keep a current medication list and bring it to your visit, we are happy to copy it for your medical record. We are a part of Riverview Health Physicians. We do accept most insurance plans, but it is your responsibility to verify that Riverview Hospital is on your plan and to get an appropriate referral from your primary care doctor when needed. Insurance Information needs to be legible and complete if you would like us to bill a health insurance policy. In order to help us process your bill with health care insurance companies please bring your insurance card(s), a photo identification card with you to each visit and be prepared to pay your required co-insurance. We look forward to seeing you. Please do not hesitate to contact us if you have any questions. Sincerely, Jeffrey R. Ginther, MD., F.A.C.S. Riverview Orthopedics and Sports Medicine

2 Riverview Orthopedics and Sports Medicine 2017 Billing Policies This practice is part of Riverview Health Physicians. We expect full payment at the time of service. Cash, checks and credit cards are accepted. While we will bill your primary health care insurance directly, remember that payment for services is the patient s responsibility and the patient is responsible for any balances not paid by insurers. We recommend that patient's verify their coverage with their insurance carriers prior to receiving medical care. Please remember that regardless of insurance coverage, you as the patient have the option of receiving any recommended medical service and may pay for it directly. We do not delay your responsibility to pay promptly due to any legal proceedings you may be pursing (e.g. accidents in home, work, auto). Patients with Health Care Insurance: 1. We accept most health insurance plans. We will bill your primary health care insurance directly. Patient co-pays are expected at the time of service. Deductibles must be paid in a timely manner. 2. If payment is not received from your insurance carrier within 45 days, please call them and question the delay. If there are extended delays, please call our office and make arrangements to begin making regular payments. If insurance pays, any overpayments will be refunded. 3. It is the patient s responsibility to have up-to-date referrals in place if required by insurance policy. Patients evaluated without referrals are responsible for the charges associated with that evaluation. X-ray Charges: You will be billed by Riverview Hospital for the technical component of x-rays and by this office for the reading fee (professional component). Uninsured: Riverview Hospital will offer discount to uninsured patients. Extenuating Circumstances: If you have extenuating circumstances and are unable to pay a bill, please discuss these with the office manager to establish a payment plan. If payment plan is not adhered to, account will be turned over to collection agency. Completion of Insurance Forms & Copies of Medical Records: 1. Completion of insurance forms $15.00 Fee Minimum (additional fee for lengthy forms) Please allow 5-7 business days to complete insurance forms. 2. Copies of Medical records HealthPort is our contract provider that copies Medical Records. Their fee schedule is available upon request.

3 RIVERVIEW ORTHOPAEDICS & SPORTS MEDICINE Patient Name: Patient DOB: REVIEW OF SYSTEMS/PATIENT MEDICAL HISTORY Please identify any signs or symptoms that you may be experiencing or have experienced. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor s office of any changes in my medical status. C a condition that you CURRENTLY have P a condition you have had in the past General Systems Recent weight gain # Recent weight loss # Fever C P Persistent Infections C P Skin: Skin Color Changes in legs C P Open Sores C P Psoriasis C P Active Skin Infection C P HEENT Blurred Vision C P Double Vision C P Wear glasses/contact lenses C P Hearing Loss C P Chronic sinus problems C P Sore throat C P Voice changes C P Neck Neck stiffness C P Swollen glands C P Respiratory Chronic cough C P Frequent cough C P Shortness of breath C P Wheezing C P Emphysema C P Tuberculosis C P Positive TB test C P Cardiovascular Chest pain or angina pectoris C P High blood pressure C P Low blood pressure C P Irregular heartbeat C P Gastrointestinal Nausea C P Vomiting C P Rectal bleeding C P Blood in stool C P Vomiting Blood C P Peptic Ulcer C P Hepatitis C P Chronic liver disease C P Genitourinary Burning or painful urination C P Blood in urine C P Kidney disease C P Kidney stones C P Frequent urination C P Musculoskeletal Back pain C P Muscle weakness C P Arthritis C P Rheumatoid Arthritis C P Lupus Arthritis C P Gout C P Ankle Swelling C P Joint Pain C P Active Infection of Joint C P Neurological Light headed or dizzy C P Migraine headaches C P Seizures C P Stroke History C P Frequent headaches C P Dementia C P Progressive Neurological Disorder C P Psychiatric Depression C P Insomnia C P Endocrine Excessive thirst C P Prescription steroid use C P Thyroid problems C P Diabetes C P Hematologic/ Lymphatic Anemia C P Tendency to bleed C P Tendency to bruise C P Phlebitis C P Blood clots in legs C P AIDS/HIV C P Height Weight Medical Record # Date:

4 Riverview Orthopedics Patient Name: DOB: Date: Current Family Physician Name and Phone Number: Dentist Name and Phone Number: Significant Family Member Medical History Patient Social History Where do you currently reside? Independently In an Assisted Living Facility In a Nursing Home Employer & Occupation: List all physicians you are currently seeing ( First and Last Name): Marital status: Single Married Separated Divorced Widowed Use of alcohol: Never Rarely Moderately Daily Drinks/ wk (hard alcohol, beer and/or wine) Use of tobacco: Never Rarely Previously, but quit, when? Currently packs/ day years Use of drugs: Never Rarely Previously, but quit, when? Please Print Your Current Medications, Vitamins and Herbal Supplements Or give receptionist a printed list to copy. ALLERGIES: (DRUGS, METALS (Cobalt, Aluminum, Chromium, Nickel), FOODS PLEASE GIVE NAME AND WHAT HAPPENED: PRIOR INFECTIONS: (SEPSIS, BACTEREMIA, OPEN WOUNDS, etc.) Past Surgical History (Procedure, Date and Doctor) Medical Record #

5 RV ORTHOPAEDICS: NEW PROBLEM/COMPLAINT FORM NAME: DOB: DATE OF VISIT: REFERRED BY: PRIMARY CARE PHYSICIAN: ====================================================== What are we seeing you for? Hip Knee Which Side? RIGHT LEFT BOTH Have you seen anyone for this pain? (Specify Who) Is this a work comp injury? (If yes, please have your employer contact us). Date the symptoms occurred? Was there a specific injury? If so, what? How severe is the pain at it s worse? (Please circle): Mild Mild-Moderate Moderate Moderate Severe Severe How would you describe the pain? (Please circle) Ache Stabbing Cramping Burning Other: What make the pain better? What makes the pain worse? Describe where the pain is located? Have you had any imaging done? (Circle all that apply): X-rays CT Bone Scan MRI What facility or hospital performed the imaging? Have you had any previous treatment? (Circle all that apply): Physical Therapy Home Exercise Program Muscle Strengthening and Flexibility Exercises Cortisone Injections Hyaluronic Injections Bracing Previous Surgery Do you use any kind of ambulatory assistive device such as a cane or walker? Does the pain cause you to restrict your daily activities? Have you taken any medication to relieve the symptoms, including over the counter medications (Ibuprofen, Tylenol, Anti-inflammatories)? Have you participated in any weight reduction program as appropriate? Are you employed outside the home? If so, what is your line of work? Medical Record#