OrthoNeuro SpineMed SportMed WorkMed

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1 OrthoNeuro SpineMed SportMed WorkMed A Multi-Specialty Center of Excellence Today s Date: Patient Registration Form Please Complete Both Sides Entirely Last Name: First Name: M.I.: Address: City: State: Zip: Home Phone: ( ) - Cell Phone: ( ) - Sex: Male Female SS#: - - Date of Birth: / / Preferred Language: Race: Ethnicity: Marital Status: Single Married Divorced Widowed Other Are you employed? Yes No Disabled Retired Other Employer: Employer Phone: ( ) - Are you a student? Yes No Name of School: Spouse s Name: SS#: - - Date of Birth: / / Emergency Contact: Phone: ( ) - Relation to Patient: If the patient is a minor under age 18, please list the responsible party. Last Name: First Name: Relation to Patient: Sex: Male Female SS#: - - Date of Birth: / / Address: City: State: Zip: Home Phone: ( ) - Cell Phone:( ) - Other:( ) - Marital Status: Single Married Divorced Widowed Other Are you employed? Yes No Disabled Retired Other Employer: Employer Phone: ( ) - Medical Insurance Information Primary Insurance Company: Phone: ( ) - Claims Address: City: State: Zip: Subscriber ID / Policy Number: Group Number: Name of Insured: Insured s DOB: / / Insured s SS#: - - Insured s Employer: Secondary Insurance Company: Phone: ( ) - Claims Address: City: State: Zip: Subscriber ID / Policy Number: Group Number: Name of Insured: Insured DOB: / / Insured s SS#: - - Insured Employer: 11/2012 wm Please Continue on Other Side

2 For Workers Compensation Claims Please complete the following: Date of injury: Employer at time of injury: / / Address: City: State: Zip: Name of Workers Comp Insurance Co: CLAIM #: Contact Person: Phone: ( ) - Doctor of record for this claim: For Auto, or Other Insurance Claims Please complete the following: Date of Accident or Injury: CLAIM #: Auto or Other Insurance Company: Phone: ( ) - Claims Address: City: State: Zip: Adjuster s Name: **Please note that it is OrthoNeuro policy to not bill Third Party Insurance or to accept Letters Phone: ( ) - of Protection**** Is the patient allergic to any medications? Yes No If yes, please list: Preferred Pharmacy Name: Pharmacy Phone: Address: Yellow Pages Internet Website Physician (please complete below) How did you hear about us? Friend / Family Member / Patient Advertisement Other ** Referred By: Phone: ( ) - Do you have a Primary Care Physician (PCP)? Yes No Primary Care Physician: Phone: ( ) - If you have any questions, or are not sure how to answer any of these questions, please do not hesitate to ask for help. Is this visit related to an accident or injury? Yes No If Yes, is the accident or injury: *Work related? Yes No *School Event related? Yes No *Auto Accident? Yes No *Other accident? Yes No Please describe: I hereby authorize my insurance carrier to pay medical and/or surgical benefits directly to OrthoNeuro Consultants. I authorize OrthoNeuro Consultants to release any information, acquired in the course of my treatment, needed for my medical insurance claim(s). A photocopy of this authorization is to be considered valid as the original until revoked by me in writing. I understand that I am financially responsible for all charges made to my account whether or not an insurance company, attorney or other third party payor is involved with payment. I understand that I am responsible for all co-payment and co-insurance amounts, non-covered supplies and services, and yearly deductibles. I understand that copays are expected at the time services are rendered. I certify that the above information is correct to the best of my knowledge. Patient/Guardian Printed name: Patient/Guardian Signature: Date: (Responsible Party) Revised WM

3 Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: Male Female DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations. Mark areas of radiation using an arrow. Include all affected areas. Dull Aching X X X X Burning === === === === Numbness === * * Stabbing ** Pin and Needles Muscular Cramp R L L R Please circle or mark with an X on this line the level or intensity of pain, discomfort that you are currently experiencing. / / no pain pain as bad as it could be

4 A.) What is the nature of today s visit? Date accident or symptoms occurred. Is this work related? Yes No Is this the first time you have had this problem? Yes No Give a detailed description of the event: List any physicians you have seen for this problem: Do you have trouble with (please circle) Weakness Bladder Bowels Walking (how far) Bending Twisting Dressing Lifting (how much) Sitting (how long) Car Rides Sleep Morning Stiffness Changes in Weather Stairs (how many flights) Lying Down Numbness Fever Chills Rashes Joint Swelling Other Currently (today) how severe is the pain in your spine (neck or back)? no pain intolerable Currently (today) how severe is the pain in your limb (arms or legs)? no pain intolerable How often does the pain interrupt your sleep? not at all occasionally half of the time often always never sleep well Is your pain (please circle) CONSTANT INTERMITTENT VARIES B.) Occupation Date last worked How long have you been with this job? Exercise Habits: (please describe) Hobbies: C.) Treatment up to date: (please circle) Osteopathic Chiropractic Physical Therapy Injections Bracing Traction Surgeries Describe: 2

5 D.) PLEASE LIST BELOW Allergies to medication: CURRENT medications (prescriptions, over-the-counter, herbal and vitamin (nutritional supplements) for this problem (name, dose, frequency, route of administration) Other CURRENT medications: (name, dose, frequency, route of administration) Prescription and non-prescription medications taken in the PAST (indicate if it is for the current problem): Other medical problems: Heart Disease Lung Disease Cholesterol Dental Disease High Blood Pressure Brain Tumor Encephalitis/ Meningitis Headaches Thyroid problems Panic Attacks Mental Illness Depression Cancer Stroke Diabetes/Hypoglycemia Glaucoma Kidney Disease Sinusitis Ear Infection Arthritis (osteo/rheumatoid) Ulcer/Stomach Disease Skin Disorder Sore Throat/Tonsillitis Mononucleosis Lumps/Cysts Deep venous Thrombosis/ Thrombophlebitis Bleeding Disorders/Anemia Hepatitis A or B / Liver Disease Aneurysm Bronchitis/Asthma Sleep Disorder Seizure/Epilepsy Tuberculosis Other: explain Other: explain Surgeries and hospitalizations (where, hospital/city, type of surgery/treatment): 3

6 E.) Check any that apply Single Married Divorced Widowed How many children do you have and their ages: How much do you smoke per day? How many years have you smoked? Do you use smokeless tobacco? Yes No Please indicate how much alcohol you consume: Beers per week Glasses of wine per week ounces (drinks) of liquor per week Have you in the past or do you use recreational drugs? Yes No Last year of school completed? What is your support system? F.) Indicate who among your close relatives may have any of the following ailments? Heart Disease Seizure or Epilepsy Cancer Brain Tumor Lung Disease Headaches High Blood Pressure Thyroid Cholesterol Arthritis Stroke Muscular Disease Ulcer Spine Problems Diabetes Panic Attacks Hypoglycemia Mental Illness G.) Which test have you had in the past? (where, when and results) MRI: EEG: Disc Injections: X-Rays: Bone Scan: Cat Scan: Myelogram: EMG / Nerve Conduction Study: H.) What is your height? Weight? 4

7 I.) Review of Systems Yes No Do you have a fever? Do you have a skin rash? Have you gained or lost weight in the last six months? How much Are you intolerant of heat or cold? Do you sweat heavily at night? Any skin lumps, cysts, or lesions? Any changes in skin, hair, nail or teeth? Do you have eye pain, redness, or inflammation? Has your vision been blurred or doubled? Have you ever lost vision in one or both eyes? Do you experience dizziness or lightheadedness? Have you ever fainted, passed out or blacked out? Do you have difficulties with balance or unsteadiness? Do you have ear pain or fullness? Do you have hearing difficulties or ringing in your ears? Does your face become numb or lose sensations? Is your sense of smell or taste disturbed? Are your teeth sensitive to cold, hot, or other? Do you have sinus discharge, blood or mucus? Do you have chest pain? Does your heart race or skip beats? Do you become short or breath? Do your feet or ankles swell? Do you cough up phlegm or blood? Do you have a persistent cough or wheeze? Any pain or discomfort in your abdomen? Has your appetite changed? Have you had nausea or vomiting? Do you suffer from constipation, diarrhea or excess gas? Have there been any changes in your bowel movements? Have you been jaundiced? Do you have burning or pain with urination? Do you have to get up often at night to urinate? Do you experience weakness of the arms or legs? Any numbness or tingling of the arms or legs? Do you have headaches or facial pain? Do you have neck or back pain? Do you have muscle pain or swelling? Do you have joint pain or swelling? Do you have difficulty with concentration or memory? Do you often feel depressed? Do you often feel anxious or nervous? Do you often feel tired or sleepy? Do you have difficulty falling asleep or staying asleep? Do you have suicidal thoughts? Sign Here 5

8 FINANCIAL POLICY Thank you for choosing us as your healthcare provider. We are committed to providing you with the best possible care. Your clear understanding of our financial policy is important to our professional relationship. Please understand that payment of your bill is considered part of your overall treatment. In order to keep your cost of healthcare to an absolute minimum, we have adopted the following policies. Fees and Payments Fees are standardized and are based on the complexity of your visit or procedure. Payment of copayments and any outstanding balance(s) is required at the time of service. We accept cash, personal checks, money orders, Visa, and MasterCard. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date that service(s) are rendered. In order for us to file a claim, you must present a current copy of your insurance card at each visit and communicate any changes in your personal contact information. Most insurance policies specify that some of the cost of the patient s care is the patient s responsibility. This can be accomplished through any combination of co-payments, co-insurance or deductibles. Copayments are due when you check in for you appointment. Co-insurance and deductibles are determined by your insurance company and reported to us on your explanation of benefits (EOB). Once we are notified, we will send you a statement. This charge is payable upon receipt of the statement. Once payments are received, they will be automatically applied to the oldest outstanding balance on your account. If you would like a payment to be applied to a specific charge, please notify our staff at the time of payment. It is not the policy of OrthoNeuro to hold your account for settlement of a legal suit. In the case of an open claim through an auto or homeowners insurance, you are responsible for the specific charges. Federal and state laws and insurance company contacts prevent OrthoNeuro from adjusting off co-pays, deductibles and any other patient responsible balance after insurance has paid. Insurance Plans Your insurance coverage is a contract between you, your employers and the insurance company; we are not a party to that contract. We must emphasize that as healthcare providers, our relationship is with you, not with your insurance company. Before your visit, please contact your insurance company to verify the physician and the facility at you are scheduled with participates with your plan and that the service(s) that you intend to receive are covered. In addition, because some insurance plans require either pre-certification and/or a referral from a primary care provider before you can be seen, please ask if these are required and obtain them if necessary. Not all services are a covered benefit in all plans so it is very important that you understand the provisions of your individual policy. Some insurance companies select certain services that the will not (continues on back) 7/15/2013

9 cover; so we cannot guarantee payment of all claims by your insurance company. If you insurance company pays only a portion of your claim or rejects your claim, they will notify you through an explanation of benefits (EOB). Reduction or rejection of your claim by your insurance company does not relieve you of your financial obligation for your charges. Surgery Charges Patients undergoing surgical procedures will receive separate bills for: Physician fee for surgery Physician Assistant fee for surgery (if needed) Physician fee for Inter-Operative monitoring (if needed) Facility fee (hospital or ambulatory surgical center (ASC)) Anesthesia (if provided separately by anesthesiologist) Please contact the hospital/facility or anesthesiology provider directly to discuss any questions with your bill from these providers. Making and Keeping Appointments If you need to cancel your appointment, please call at least 24 hrs. in advance. This allows us to accommodate other patients who need to be seen. Excessive cancellations or no shows may result in being dismissed from the practice. Non-Payment of Outstanding Accounts Accounts that are not paid in a reasonable amount of time may be sent to an external collections agency and reported to the credit bureaus. If this occurs, you may be required to pay the outstanding balance in full plus any applicable fees prior to coming back into the practice. Administrative Fees Forms Charge If your employer requires Family Medical Leave Act (FMLA) or Disability paperwork to be completed by your provider, the turnaround time is seven (7) business days and there is a $25 fee for this service, payable in advance. Medical Records Charge If you would like a copy of your medical records sent to yourself or another physician, these copies are billed on a per page basis, payable in advance, in accordance with HIPAA and Ohio state law. The per page fee schedule is available upon request. If a collaborating physician (primary care or specialist) request portions of your chart to assist in your care, there is no charge. Returned Check Fee Non Sufficient Funds (NSF) checks are subject to a $25 fee (in addition to fees from your bank)

10 AUTHORIZATIONS I, the undersigned agree and authorize the providers of OrthoNeuro to provide the following: Authorization to Provide Care I authorize the providers of OrthoNeuro to provide any medical care deems necessary according to their professional opinions. Authorization and Release of Information for Billing I authorize my insurance benefits to be paid directly to OrthoNeuro. I authorize the release of any information by OrthoNeuro to my insurance carrier, pertinent to my health insurance claim. I understand that I am financially responsible for this account unless other arrangements have been made. Patient Certification, Authorization to Release Medical Information I, the undersigned authorize OrthoNeuro to release any medical information that may be necessary to request claim reimbursement from the insurance carriers or other payers to whom claims have been or are being submitted. Credit Information and Collection Fees I, the undersigned agree that if payment on this patient s account is not made I will pay reasonable attorney s fees and 30% collection fees incurred for the collection process. I also authorize the release of credit information to the appropriate information gathering agencies. Prescription Medication History I, the undersigned agree that OrthoNeuro may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payers for treatment purposes. I have reviewed the OrthoNeuro Financial Policy and Authorizations: Please initial: I certify that I have read the foregoing and I am the patient or am duly authorized to execute the above agreement for the patient and accept its terms. Responsible Party: Relationship to Patient: Self Parent/Guardian Signature: Date: Printed Name:

11 Orthopedic & Neurological Consultants, Inc. Acknowledgment by Individual or Personal Representative of Receipt of Notice of Privacy Practices I acknowledge receiving a copy of the Notice of Privacy Practices given to me by Orthopedic & Neurological Consultants, Inc.. I understand this Notice explains how Orthopedic & Neurological Consultants, Inc. is permitted to Use and Disclose my Protected Health Information. I understand I should keep the Notice and refer to it if I have questions. I also understand I should call the Orthopedic & Neurological Consultants, Inc. Privacy Officer at (614) if I have a question or concern about my privacy rights. Print name of Individual (If applicable) Print name of Individual s Personal Representative and Relationship to Individual Signature by Individual or Individual s Personal Representative Date OFFICE STAFF USE ONLY IF ACKNOWLEDGMENT NOT SIGNED The following attempt(s) were made to obtain a written Acknowledgment of Receipt: NPP given to Individual, who refused to sign. NPP was mailed to Individual s home address as stated in records. NPP was mailed to an alternate address, at Individual s request. NPP was faxed or ed to Individual, at Individual s request. Other reason(s) why written acknowledgment not obtained: Signature of Person attempting to obtain signed Acknowledgment Date ORIGINAL MAINTAINED IN FILE v2