Signature of Patient or Guardian

Transcription

1 Financial Policy Thank you for choosing us as your orthopaedic specialists. We are committed to providing you the best possible care & are pleased to discuss our professional fees with you at any time. The following is a statement of our Financial Policy which we require you to read and sign prior to any medical services. FULL PAYMENT IS EXPECTED AT THE TIME OF SERVICE. ALL PAYMENTS WILL BE COLLECTED UPON CHECKING IN FOR YOUR SCHEDULED APPOINTMENT. WE ACCEPT CASH, PERSONAL CHECKS, VISA, AND MASTERCARD. INSURANCE If we are a participating provider with your insurance plan you are responsible for all co payments deductibles and any non covered services at the time of service. As a courtesy we will file insurance claims with most insurance carriers, provided you have supplied us with the proper information. If we are NOT a participating provider with your insurance plan you are responsible for full payment at time of service. If you need to file your own insurance our office will provide you with the proper documentation. Bills for surgery will not include charges of anesthesia, hospitalization, or laboratory test. These are billed separately, from the facility where the surgery is performed. MINOR PATIENTS The adult parent or guardian accompanying the minor is responsible for payment of the minor patient s account regardless of who the insurance policy holder is. For unaccompanied minors non emergency treatment can be denied until a parent or guardian is present or we have written permission for treatment and payment of the account period. WORKMAN S COMPENSATION All workmen s compensation claims must be verified in writing by the employer. Verbal or telephone verifications are not acceptable. If you have seen another physician for the same complaint an authorization for a change of physician must be verified on your company s form. PERSONAL INJURY WITH ATTORNEY If you are being represented by an attorney or a third party payer, we will provide you with the proper information to file your claim. You are responsible for full payment to our office at the time services are rendered. AUTOMOBILE ACCIDENT If you were in an automobile accident and you have Med Pay automobile insurance our office will provide you with the proper documentation to file the claims. It will be your responsibility to file the claims. If you have health insurance we will file a claim for all professional services received. FORMS: We will be happy to complete any medical forms. Payment of $20.00 is required prior to completion of each form(s). Please allow 7 10 business days for your form to be completed. We will notify you when the form is ready. MISSED APPOINTMENTS Failure to give 24 hour notice of cancellation of your appointment will result in a $25.00 fee billed directly to you. We will not bill your insurance company for this amount. You will be responsible for prompt payment of this fee prior to being seen at your next scheduled visit. COLLECTIONS If your account balance becomes past due and is sent to an outside collection agency, you will be responsible for any additional fees incurred. All monthly statements are due and payable in full upon receipt. All returned checks are subject to a $25.00 service fee. If you need to make special payment arrangements this needs to be brought to our attention prior to being examined. Your signature below indicates that I understand and agree to this financial policy. Signature of Patient or Guardian Date

2 Prescription Refills I agree that Wake Orthopaedics, LLC may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payors for treatment purposes. I understand that Wake Orthopaedics, LLC requires 48 hours to process my refill requests. Prescription refills will not be processed Saturdays, Sundays or Holidays. Patient or responsible Party Signature Date Capital City Surgery Center, LLC I understand that during the course of my physician/patient relationship with the physician, the physician may refer me to Capital City Surgery Center, LLC ("the Center"), which is an ambulatory surgery center located at 23 Sunnybrook Road, Raleigh, North Carolina, In connection with any such referral, the physician hereby advises you that such physician or one or more physicians providing services to you at the Center may have an ownership interest in or other financial relationship with the Center. Please be advised that you have the right to obtain the health care items and services for which the physician refers you, at any location or from any ambulatory surgery center, hospital, provider, or supplier of your choice, including the Center. Patient or responsible Party Signature Date

3 COMPOUND AUTHORIZATION I have been asked whether I choose to designate other persons/entities to receive my health information. I do not choose to designate such persons on the Compound Authorization form. I give my permission to WakeMed Faculty Physicians to release listed information to the entities named below. Spouse / Significant Other (provide name): Financial/billing Information Medical Information as follows: Labs* Diagnostic Tests* Appointments General medical information/condition Parent / Family Member or Other (specify relationship & provide name): Financial/billing Information Medical Information as follows: Labs* Diagnostic Tests* Appointments General medical information/condition Employer / Workers' Compensation (provide name): Information about return to work and/or work restrictions, and any absences that result from appointments. School / Preschool / Day Care (provide name): Information about any absences that result from appointments Activity Restrictions Physicals and/or Well-Child Examination *Lab and diagnostic results will not be left on voice mail. Rights of the Patient I understand the medical information to be disclosed may include information regarding psychological or psychiatric impairment, a communicable disease (such as sexually transmitted disease, HIV/AIDS, tuberculosis, or hepatitis), mental illness, alcohol or substance abuse. I understand that I have the right to revoke this authorization in writing at any time, except to the extent that the information has already been released pursuant to this authorization. Otherwise, this authorization shall continue to be valid only for as long as reasonably necessary to carry out the purposes listed above or one year, whichever is the earlier date. I understand that treatment will not be conditioned upon my completion of this authorization. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. Patient/Representative Signature: Witness: Date: Patient unable to sign Please note that the information disclosed pursuant to this authorization may be subject to re-disclosure by a recipient of such information and would no longer be protected under the terms of the federal privacy rule. Revocation / Amendment Name/Signature: Date: Staff Use Only: Compound Authorization Obtained By Telephone Authorized Person Giving consent:: Telephone #: Relationship to patient: Witness: Witness: Date: Time: WakeMed Faculty Physicians Compound Authorization LABEL REV. 9/07 WFP-104

4 New Patient History Form FOR US TO PROCESS YOUR CHART, PLEASE COMPLETE FULLY AND PRINT CLEARLY PATIENT NAME: REFERRING DOCTOR: WHAT IS YOUR MAIN COMPLAINT? PRIMARY CARE DOCTOR: PATIENT D.O.B: PLEASE CHECK SIDE AND BODY PART SIDE (Circle One) Right Left Both Shoulder Hand Elbow Back Hip Foot / Ankle Knee Finger (circle one) Fracture Thumb Index Middle Ring Small Finger VITAL SIGNS: Height: Weight: PAIN SCORE (0-10): PAIN STATUS (circle one): (Improving) (No Change) (Worsening) ALLERGIES: None Allergy: Allergy: Allergy: Allergy: Reaction: Reaction: Reaction: Reaction: PHARMACY: CURRENT MEDICATIONS AND DOSAGE: None (Please list on back if you need additional space) SUPPLEMENTS: Fish Oil: (Yes) (No) Gingko Biloba: (Yes) (No) Vitamin D: (Yes) (No) Calcium: (Yes) (No) Glucosamine/Chondroitin: (Yes) (No) PAST SURGICAL HISTORY: (Check All that Apply) All Negative Achilles repair Elbow Surgery Open knee surgery Arthroscopic knee surgery Foot or ankle surgery Open shoulder surgery Arthroscopic shoulder Hand or finger surgery Pacemaker/defibrillator surgery Back decompression Hip or knee replacement Pelvic surgery CABG Hip surgery Wrist Surgery Coronary stent Neck fusion Other: PAST MEDICAL HISTORY: (Check All that Apply) All Negative Anemia Fracture-last 5 years? Osteoporosis Anxiety GI Bleeding Psoriasis Asthma Gout Pulmonary embolism 1

5 Blood Clots/DVT Heart Attack Rheumatoid arthritis Bone Density Test Date: Hepatitis (specify B or C) Seizures Cancer High Cholesterol Staph infection Cardiac arrhythmia Hypertension Stroke Chemo/radiation Kidney Disease Thyroid Disease Chronic steroid use? MRSA Ulcers (GI) Depression MSSA Other: Diabetes mellitus Multiple Sclerosis FAMILY MEDICAL HISTORY: (Check All that Apply) All Negative Condition Relationship to Condition Relationship to Patient Patient Heart Disease Diabetes Lung Disease Tuberculosis Alzheimer s Disease Parkinson s Cancer Multiple Sclerosis Stroke Osteoarthritis Scoliosis Rheumatoid Arthritis Seizures OTHER: SOCIAL HISTORY Alcohol Use (Circle One): (Yes) (No) Drinks/Week: Glasses of Wine Cans of Beer Shots of Liquor Drinks containing 0.5 oz of alcohol Drug Use: (Circle One): (Yes) (No) Frequency Per Week: Comments: Type(s): Tobacco Use: (Circle One): (Current Everyday) (Current Someday) (Former) (Never) Packs/day (Circle One): Other: Quit Date:. Smokeless Tobacco (Circle One): (Current User) (Former User) (Never) Quit Date: OCCUPATION: FEMALE PATIENTS ONLY: Are you pregnant, or is there a chance you may be pregnant? (Yes) (No) REVIEW OF SYSTEMS: (Circle All that Apply OR Check All Negative Under Each Section) All Negative + Fever + Skin Rash + Chills + Shortness of breath + Wound drainage + Frequent Falls + Leg Swelling + Heart Murmur + Unexplained Weight Loss + Other 2