Glenn D. Cohen M.D. Brian D. Rudin M.D. Orthopedic Surgery

Transcription

1 Glenn D. Cohen M.D. Brian D. Rudin M.D. Orthopedic Surgery 696 Hampshire Rd #180 Westlake Village, CA Heading North on Fwy 101 Exit Hampshire Rd. and turn left Turn left on Triunfo Canyon (Traffic Signal) Turn right into the first parking lot Drive past the building to the end of the parking lot and turn right Park closest to Hampshire Rd., walk along the front of the building on Hampshire o Our suite is #180*, the second door on the right *Our entrance is not located within the building; it is a separate entrance from the front of the building facing Hampshire Rd. Heading South on Fwy 101 Exit Hampshire Rd. and turn right Turn left on Triunfo Canyon (Traffic Signal) Turn right into the first parking lot Drive past the building to the end of the parking lot and turn right Park closest to Hampshire Rd., walk along the front of the building on Hampshire o Our suite is #180*, the second door on the right *Our entrance is not located within the building; it is a separate entrance from the front of the building facing Hampshire Rd. From the 23 Merge onto the 101 South Exit Hampshire Rd. and turn right Turn left on Triunfo Canyon (Traffic Signal) Turn right into the first parking lot Drive past the building to the end of the parking lot and turn right Park closest to Hampshire Rd., walk along the front of the building on Hampshire o Our suite is #180*, the second door on the right *Our entrance is not located within the building; it is a separate entrance from the front of the building facing Hampshire Rd.

2 Glenn D. Cohen, M.D. Brian D. Rudin, M.D. Orthopedic Surgery PATIENT REGISTRATION FORM Patient Information Last Name First Middle Street Address City State Zip Code Home Phone ( ) Cell Phone ( ) Social Security No. Date of Birth Age Sex M / F Marital Status: Single / Married / Divorced / Widowed Address: Who referred you to the Dr.? Employer Information Patient s Occupation Circle One: Full time / Part time / Retired / Student. If Student, Name of School Spouse Information Spouse s Name Date of Birth Soc. Sec. No. Responsible Party Information only fill out if patient is a minor (this is the person that brings the minor to their first appointment) Responsible Party Date of Birth Soc. Sec. No. Address Phone ( ) Relationship to Patient: AUTHORIZATION FOR MEDICAL TREATMENT I, (Fill in your name), (if patient is a minor, I, (your name), as Parent/Guardian of (Patient s name)) hereby authorize Glenn D. Cohen, M.D., Brian D. Rudin, M.D., associates and assistants as designated by Dr. Cohen and Dr. Rudin to perform evaluation and treatment of my orthopaedic condition(s). I further require and authorize Glenn D. Cohen, M.D., Brian D. Rudin, M.D., associates and assistants, to perform additional procedures, as they may deem immediately necessary on an emergent basis. I understand that elective surgical procedures will be consented separately. I consent to the administration of medications and injections (also consented separately) deemed necessary in the judgment of Glenn D. Cohen, M.D., Brian D. Rudin, M.D., associates and assistants as designated by Glenn D. Cohen, M.D. and Brian D. Rudin, M.D. I also consent to the photographing and the publication of any procedure(s) to be performed provided my identity is not revealed and that the use is limited to medical, scientific, or educational purposes. I waive all rights that I may have to any claims for payment in connection with the exhibition of the photographs. I recognize that the practice of medicine and surgery is not an exact science, and Dr. Cohen and Dr. Rudin do not guarantee the results of treatment. Signature Date

3 Glenn D. Cohen, M.D. Brian D. Rudin, M.D. Orthopedic Surgery ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I hereby acknowledge that I received a copy of this medical practice s Notice of Privacy Practices. I further acknowledge that a copy of the current notice is posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment. FINANCIAL POLICY Thank you for choosing Glenn D. Cohen, M.D. and Brian D. Rudin, M.D. The following is our Financial Policy: All patients will provide accurate and complete personal and insurance information. All applicable co-pays, coinsurance, deductibles and personal balances (current and prior) are due at the time of service. Payment can be made by cash, check, Visa or Mastercard. Insurance: The doctors are not a participating provider in any managed care, HMO products, MediCal or Medicare. Dr. Cohen does participate in some plans administered by Blue Cross. Dr. Rudin does participate in some plans administered by Blue Cross, Blue Shield and Tricare. Dr. Cohen and Dr. Rudin voluntarily withdrew as providers from numerous health plans. There are a large variety of plans and products introduced on almost a daily basis. Therefore, it is YOUR responsibility to contact your insurance company prior to being treated to determine if Dr. Cohen and/ or Dr. Rudin are a provider on your plan and to verify any co-pays, coinsurance, deductibles and non-covered services under your policy. Financial Difficulties: It is your responsibility to disclose any concerns that you might have regarding payment of your bill prior to seeing the doctor. We will make every effort to assist patients who bring this issue to our attention before services are provided. Missed Appointments: All appointments not cancelled at least 24 hours in advance will result in a $35.00 charge for the first incident and a $60.00 charge thereafter. Patients with a pattern of canceling or missing appointments will be seen on a walk-in basis only. Past Due Accounts: Within 30 days of treatment, any additional payment not made at the time of services is expected in full. All accounts will be assessed interest charges at a rate of 18% per annum on all unpaid balances greater than 30 days following the DATE OF SERVICE. We submit claims to your insurance company as a courtesy to all of our patients. If your insurance carrier requires additional information from you in order to process your claim and you do not provide it, you will be responsible for full payment of all services immediately. Surgery: When possible, prior to scheduling surgery, an estimated surgical cost analysis will be provided. It is your responsibility to pay the deductible, coinsurance or any outstanding balances on your account at least five (5) days prior to the date of your scheduled surgery. There will be a $250 cancellation fee for all non-medical cancellations. DME Products: All splints dispensed are non-refundable. Assignment of Benefits: I hereby authorize my insurance benefits to be paid directly to Glenn D. Cohen, M.D. or Brian D. Rudin, M.D. I hereby instruct and direct my insurance company to pay by check made payable to Glenn D. Cohen, M.D. or Brian D. Rudin M.D. and mailed to 1014 S. Westlake Blvd., Suite 14, PMB #228, Westlake Village, CA I understand that I am personally responsible for payments which my insurance company/managed care company will not cover if they say that an office visit, procedure or pathology, etc is not medically necessary, pre-existing, etc or related to deductibles or co-payments, or for any other reason they give for non-payment. I also understand that what my carrier considers non medically necessary may, on the contrary, be considered medically necessary by this office. Therefore, I agree to hold Glenn D. Cohen, M.D. and Brian D. Rudin, M.D. harmless for any medical decisions made by my insurance/managed care carrier which may in any way compromise my best care and result in medical damage, loss or death. I authorize Glenn D. Cohen, M.D. and Brian D. Rudin, M.D. to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. I have read, understand and agree to the above Financial Policy. Emergency Information IN CASE OF EMERGENCY Name Relationship to patient Phone ( ) Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies may pay fixed allowances for certain procedures, they sometimes refer to as reasonable and customary fees. We do not accept this as payment in full (unless otherwise restricted by law or agreement we may have with your insurer). Also some of the insurance companies only pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance. IN ORDER TO CONTROL YOUR COST OF BILLINGS, WE DO REQUEST THAT OUR CHARGE FOR OFFICE VISITS BE PAID AT THE CONCLUSION OF EACH VISIT. In the event the account is turned over for collection, the collection fee and /or legal fees, including attorney fees, shall be your responsibility. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private insurance and other health plans to Glenn D. Cohen, M.D. or Brian D. Rudin, M.D. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure the payment, via fax transmittal or hard copy. Signature Date

4 Glenn D. Cohen, M.D. Orthopaedic & Hand Surgery PATIENT QUESTIONNAIRE PLEASE ANSWER ALL QUESTIONS Name: Age: Sex (Circle): M F Date: / / Occupation: When did you first notice this problem: / / Height / Weight? Feet Inches Pounds Has another physician treated you for this? Yes No Who? Who is your regular doctor? Which hand do you write with? Right Left Both Where are you having symptoms? Right Left Both List body parts (s) Describe the injury or development of your problem: My pain feels: Aching, Burning, Cramping, Deep Diffuse, Dull, Electric, Intolerable, Throbbing Pressured Severe, Sharp, Shooting, Stinging Do you have NUMBNESS OR TINGLING? Yes No IF NO, SKIP TO I HAVE PROBLEMS: When does it occur? Morning Day Night Always Circle the number of times a day it occurs How long does this last? Seconds Min. Hours What makes this better? Time Nothing Medicine Other: What makes this worse? Activity Rest For This Problem, Prior to This Visit: Have you had X-rays? Yes No Have medications been prescribed? Yes No Did you attend therapy? Yes No Did you receive splints? Yes No Did you have any special tests (MRI. EMG) Yes No Have you had surgery for this problem Yes No Please explain any yes answers: Other: Where does the numbness or tingling occur? I have problems: Cooking Bathing Getting Dressed What percent of the problem is Pain % Tingling % (Total should =100%) Are you ever asymptomatic and feeling well? Yes No Do you think that you are getting better now? Yes No Have you been hospitalized? YES NEVER If yes, why and when? Circle your worst PAIN? None Severe IF, SKIP TO DO YOU HAVE NUMBNESS Pain occurs? Morning Day Night Always Circle the number of times a day it occurs How long does the pain last? Seconds Min. Hours What makes the pain better? Time Nothing Medicine Other: What makes the pain worse? Activity Rest Other: Where does the pain occur? Indicate any SURGERIES you have had: Appendix Hernia Uterus Heart Tonsils Gallbladder Tubes Tied Cosmetic Eye List other Any previous breaks or sprains of your Neck Spine Arms Forearms Hands Legs Feet? Do YOU have any of the following MEDICAL PROBLEMS? Diabetes Arthritis AIDS Heart Stroke High Blood Pressure Asthma /Lung Cancer List other

5 Do any of the following problems run in your FAMILY? Diabetes Arthritis AIDS Heart Stroke High Blood Pressure Asthma /Lung Cancer List other Check any of the following that you have had RECENTLY (Continued) No appetite Blood in Urine Hepatitis Flank Pain List any previous significant TRAUMA: Discharge Incontinence Spitting up blood Nasal Congestion or Bleeding List any drug ALLERGIES you have: Eye Disease/ Injury/ Pain Recent Vision Changes Difficulty Breathing Tuberculosis List any MEDICATIONS you take: Frequent Urinating Pain when Urinating Shortness of Breath Heart Palpitations Ankle / Feet Swelling High Blood Pressure Year of your last TETANUS shot: Do you smoke? Yes No Packs per day for years Did you quit smoking? Yes No When? Do you drink alcohol? Yes No Drinks per week Do you take drugs not from a doctor? Yes No Single Married Divorced Widowed Children Yes # No Do you live on your own? Yes No Check any of the following that you have had RECENTLY Excessive thirst Hormone problem Breast Lumps / Drainage Change in hair or nails Dribbling Neck Pain Rash or Itching Leg Pain Passing Out Seizures Excessive Urination Thyroid problems Excessive Bleeding Heat or cold intolerance Genital Pain Back Pain Chronic Sores Skin Problems Headache Dizziness Weight Loss Weakness Depression Anxiety Fever/Chills Very Tired Hallucinations Swollen Glands Sore Throat Hearing Loss Bruise easily Cancer Sinus Problems Chest Pain Eczema Allergies Drainage from eyes Cough HIV/AIDS Phlegm Nausea Diarrhea Bloody Stool Wheezes Vomiting Constipation Abdominal Pain WOMEN ONLY: Is there a possibility of pregnancy currently? Yes No EXTRA ROOM TO ELABORATE ON ANYTHING:

6 Glenn D. Cohen, M.D. Orthopedic Surgery HAND SCREENING FORM Name: Date: Please help Dr. Cohen with your diagnosis by mapping out your symptoms on the chart below. Please use the following symbols to indicate which symptoms are occurring: Pain = XXXXXX Numbness= Tingling = Left Dorsal Left Volar Right Volar Right Dorsal