Patient Demographic Information

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Horatio Francis
5 years ago
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Address City State ZIP Code E-Mail Address Home Phone Work Phone Cell Phone AGE of Birth Gender Social Security Number ETHNICITY: HISPANIC OR LATINO NON-HISPANIC OR NON-LATINO

1 Maurice Jové, M.D. Nathan Jové, M.D. Jeff Traub, M.D. Brian Vanderhoof, D.O Farhan Malik, M.D. Patient Demographic Information First Name Last Name M.I. Address City State ZIP Code Address Home Phone Work Phone Cell Phone AGE of Birth Gender Social Security Number ETHNICITY: HISPANIC OR LATINO NON-HISPANIC OR NON-LATINO DECLINE PRIMARY LANGUAGE: ENGLISH SPANISH OTHER ARABIC CANTONESE FRENCH GERMAN HINDI ITALIAN JAPANESE KOREAN MANDARIN PERSIAN POLISH BRITISH ROMANIAN RUSSIAN TAGALOG GREEK UKRAINIAN PORTUGESE VIETNAMESE RACE: AMERICAN INDIAN OR ALASKA NATIVE ASIAN WHITE BLACK OR AFRICAN AMERICAN OTHER NATIVE HAWIIAN OR OTHER PACIFIC ISLANDER DECLINED Emergency Contact: Relationship Home Number Cell Number Signature

2 PATIENT INSURANCE INFORMATION Patient Name Responsible Party Relationship (If the patient is under the age of 18) Address City, State ZIP Code Home Phone Work Phone Cell Phone of Birth Gender Social Security Number Referred By Phone Primary Care Physician Primary Insurance ID Policy Holders Name of Birth Social Security Number Secondary Insurance ID Policy Holders Name of Birth Social Security Number injuries occurred Were your injuries related to an Auto Accident Y N Workers Compensation Claim? Y N Carrier Phone Number ClaimNumber Person to verify benefits I authorize the release of any medical information necessary to process insurance claims and certify that the above information is true, I further authorize direct payment to the provider of services for medical and surgical benefits, if any. Signature

3 FINANCIAL POLICY Patient Name FOR PATIENTS WITH HEALTH INSURANCE: We bill most insurance carriers for you. We also bill most secondary insurance companies for you. We will not bill a third insurance company for you. Co-payments are due prior to service. Deductibles are due at the time of service. If your insurance requires a referral, it is your responsibility to be sure the referral is at our offices and valid prior to each appointment. Since your agreement with your insurance carrier is a private one, we do not routinely research why an insurance carrier has not paid or why it paid less than anticipated. If an insurance carrier has not paid within sixty days (60) of billing, the balance is due in full from you. WORKERS COMPENSATION PATIENTS: If you injury is work related, we will need the case number, contact information, and authorization prior to treating you. PERSONAL INJURY / AUTO INSURANCE: We will file insurance with Auto carriers if it is with your carrier. We will not file a third party claim. If this is the situation, you may pay us in full for services, we will issue a receipt, and you may get reimbursed from the auto carrier. We will not file health insurance in lieu of Auto policy. Once your benefits are exhausted, we may, at our discretion, sign an attorney lien. In all circumstances, you, the patient, are responsible for the charges. If you present us with health insurance and then subsequently receive a settlement, we reserve the right to recover, from you, any adjustments made to your account. ATTORNEY LIENS: We evaluate all Attorney Lien requests individually; if we accept the Lien, both yourself and the Attorney must sign the Lien. In the event you terminate that relationship, fees are due immediately. SURGERY FEES: Prior authorization for surgery is required for many procedures. Our office will obtain that on your behalf. Copayments, deductible, and patient responsibilities are due at the pre-operative visit unless other arrangements are made prior. We will verify the benefits and give you an approximate amount due. This is based on what we anticipate the procedures will be, if there are additional or less procedures performed, we will bill you for any remainders or issue a refund once the insurance has paid their portion. Assistant surgeons are required for the following procedures: Total Joint Replacements, ACL Reconstruction s, certain types of fracture management, and open cases. We will inform you whether or not an assistant surgeon is anticipated. In these cases, you have the responsibility to pay a maximum of $ toward the cost of the Assistant Surgeon. If your insurance company issues payment to us we will issue you a refund up to your $ SIGNATURE ON FILE AND ASSIGNMENTOF BENFITS: I request payment of authorized benefits, Medicare or otherwise, to be made on my behalf to the provider of services. I authorize the holder of information about me to release to the carrier, Health Care Financing Administration or otherwise, and its agents, any information needed to determine these benefits or benefits payable to related services. I understand my signature requests payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in ITEM 9 of the CMS 1500 form or elsewhere on other approved forms and electronic submitted claims, my signature authorizes release of information to other insurer or agency. In Medicare assigned cases, the provider agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is only responsible of the deductible and co-insurance. Co-insurance and deducible are determined by the carrier. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered as valid as an original. I understand I am responsible for the bill at the time of service unless assignment has been accepted. I FURTHER UNDERSTAND THAT IT IS MY RESPONSIBILITY TO MAKE SURE MY INSURANCE COMPANY HAS PAID THE CLAIM OR I ACCEPT RESPONSIBILITY TO PAY THE CHARGES IN FULL. I have read and understand, have had the opportunity to ask questions, and agree to the financial policy for payment of professional fees. DEKALB ORTHOPAEDIC CLINIC GWINNETT ORTHOPAEDIC & SPORTS MEDICINE

4 OFFICE POLICIES As a patient in our practice there are certain functions that we perform on your behalf that are not directly related to patient care. As to avoid misunderstandings, we have the following policies in place: 1. MISSED APPOINTMENTS: We reserve the right to charge you $50.00 for appointments that are not cancelled prior to your appointment time. These fees must be paid prior to your next appointment. Repeated misses, not cancelled appointments, may result in the dismissal from our practice. 2. There is a $25.00 cash only charge per form that we fill out on your behalf. This is for each time we fill the forms out. These forms take 5-10 business days to be ready. We will not fax the forms to your FLMA nor Disablity Insurance Company, you must pick the forms up from our office. We do not accept phone messages from FMLA nor Disabilty Ins. Companies. We will not call FMLA nor Disability Ins. Companies. 3. There are signs, forms, and phones that utilize the trade names of EXCEL Orthopaedics and Georgia Knee and Sports Medicine. In certain instances, these companies perform various office functions not related to the delivery of medical care. All medical care is delivered by physicians who are NOT employees of these groups. These physicians bill for services under various separate entities. You may see bills under the names of Atlanta Knee and Sports Medicine, Jeff Traub MD PC, Barbour Orthopeadics and Sports Medicine, Dekalb Orthopaedic Clinic, and Gwinnett Orthopaedic and Sports Medicine, and Gwinnett Bone and Joint Specialists. 4. For medical records, there is a $25.00 cash fee for copies of medical records for personal use. We will send a copy to a treating physician on your behalf for no charge. If you are a workers compensation patient and do not want to get a copy from your attorney or adjuster, the regular worker s compensation fee schedule applies each time you get records. 5. CO-PAYS are due at the check in desk prior to seeing the physician. 6. There is a $35.00 fee assessed for checks returned for insufficient funds

5 PRESCRIPTION DRUG POLICY Dear Patient, Many of you will be requiring pain control during the treatment of your orthopaedic problems and conditions. We wish to advise you of our practice s desire to control your pain but at the same time be in compliance with existing medical and state guidelines. We will provide pain control after surgery and/or acute injury for up to 90 days follow-up. Following that time period, if you still require medication, you will be required to receive pain management through your primary care practitioner or a pain management specialist. The maximum prescribable amount for chronic pain management will be limited to 60 pills per month except under extenuating circumstances. If you are already receiving pain medications from our practice we will only allow you to receive 60 pills per month. This will be done reducing your current usage over a ninety day period. There will be ABSOLUTELY NO NARCOTIC PRESCRIPTIONS FILLED AFTER 5 PM OR OVER THE WEEKENDS. Medication refills must be called into the refill prescription extension at the office where you are routinely seen. They must be called in by noon to be verified by your physician in order to be refilled within two business days. You will be required to have liver and kidney function testing via blood sampling every six months by your regular physician if you are taking narcotics for chronic pain. Without these test results we will be unable to refill your prescription needs. Only one physician can prescribe your narcotic medications at any time. We will not refill prescriptions that are lost. We cannot refill prescriptions that are stolen without a police report. Online pharmacy checks may be done to verify your narcotic usage. We regret the need to have such a stringent policy however the ever-changing face of medical mandates necessitates these actions. By signing this, you are acknowledging the Excel Orthopaedics Pain Contract

6 New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations I understand that as part of my healthcare, this organization originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment A means of communicating among the many healthcare professionals who contribute to my care A source of information for applying my diagnosis and surgical information to my bill A means by which a third party payer can verify that the services were actually provided A tool for routine healthcare operations such as assessing quality and reviewing the competency of healthcare professionals I understand and have been provided with a Notice of Information Practices that provides a more complete description of information issues and disclosures. I understand that I have the following rights and privileges: The right to review the Notice prior to signing the consent The right to object to the use of my health information for directory purposes The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, for healthcare operations. I understand that this organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign the consent or revoking this consent, this organization may refuse to treat me as permitted by Section of the Code of Federal Regulations. I further understand that this organization reserves the right to change their notice and practices and prior to implementation, in accordance with Section of the Code of Federal Regulations. Should the organization change their notice, they will send a copy of any revised notice to the address that I have provided (whether U.S mail, or if I agree, ). I wish to have the following restrictions to the use and disclosure of my health information: I understand that as part of this organization s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosure via fax or . I fully understand and accept decline the terms of this consent. Office Use Only Consent received by on Consent refused by patient, and treatment refused as permitted Consent added to the patient medical record on DEKALB ORTHOPAEDIC CLINIC GWINNETT ORTHOPAEDIC & SPORTS MEDICINE

PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP

PATIENT INFORMATION PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP HOME PHONE ( ) WORK PHONE ( ) CELL PHONE ( ) E-MAIL