Welcome to Bluegrass Regional Foot & Ankle PATIENT PAPERWORK

Transcription

1 Welcome to Bluegrass Regional Foot & Ankle PATIENT PAPERWORK Name: DOB: / / Sex: M F First Middle Last SS#: - - Address: Street City State Zip Home #: ( ) - Cell #: ( ) - Work #: ( ) -. Primary Care Provider: Last seen: Preferred Pharmacy: Ethnicity: Caucasian African American/Black Native American Hispanic/Latino Other: Marital Status: Single Married Widowed Divorced Separated Other: Employment Status: Student Full-time Part-time Unemployed Disabled Self Spouse/Parent/Guardian: Emergency Contact: Relationship: Phone #: ( ) -.Alt.#: ( ) -. How did you hear about our office? Internet Facebook Newspaper Phonebook Saw Sign Other Healthcare Provider: Patient: Primary Insurance: Are you the policy holder? Y N Policy Holder Information Name: Relationship to patient: Spouse Parent Self Other Phone #: ( ) - Sex: M F DOB: / / SS#: - - Address: _ Street City State Zip Member ID: Group #: Employer: Secondary Insurance: Are you the policy holder? Y N NOT APPLICABLE Policy Holder Information Name: Relationship to patient: Spouse Parent Self Other Phone #: ( ) - Sex: M F DOB: / / SS#: - - Address: _ Street City State Zip Member ID: Group #: Employer: Page 1

2 HISTORY OF PRESENT CONDITION What is the reason for your visit today? How long have you had this issue? What treatments have you tried & have they been effective? CURRENT MEDICATIONS Please list current medications, including topical creams, vitamins/supplements, & all over-the-counter medications: No Medications Use the back of this form if more room is needed ALLERGIES Please select any known allergies: No Known Allergies Penicillin Sulfa Adhesive Tape LATEX Betadine (iodine) Aspirin Tylenol/Acetaminophen Ibuprofen Erythromycin Codeine Other (please specify): MEDICAL HISTORY Aids/HIV Appendicitis Asthma Cancer Diabetes Emphysema Gout MS Hepatitis High Blood Pressure Pacemaker Pneumonia Seizures Stroke Ulcer Thyroid Disorder DENIES ALL Other: SURGICAL HISTORY Angioplasty Ankle Appendectomy Back C-section Eye Foot Hip Replacement Knee Nail Removal Foot Hip Replacement Knee Thyroid Tonsillectomy Heart Vascular Wisdom Teeth {Amputation of:} Toe Foot Leg DENIES ALL Other : FAMILY HISTORY Cancer Depression Diabetes Genetic Disease Heart Disease High Blood Pressure Stroke High Cholesterol Rheumatoid Arthritis DENIES ALL Other: Page 2

3 SOCIAL HISTORY Smoker # packs per day Alcohol Use # drinks per week Tobacco Usage Illegal Drug Usage History of Alcoholism History of Drug Addiction Former Smoker DENIES ALL MUSCULOSKELETAL Back Pain Heel Pain Hip Pain Morning Stiffness Muscle Tenderness Joint Swelling Leg Cramps Weakness in Legs DENIES ALL SKIN Athlete s Foot Blisters Burning of Skin Dry/Scaly Skin Leg Ulcer Non-Healing Wounds Rash Tingling Sensation DENIES ALL NEUROLOGICAL Burning in Feet Numbness Paralysis Seizures Tingling DENIES ALL GASTROINTESTINAL Blood in Stool Constipation Diarrhea Heartburn/GERD Hemorrhoids Vomiting Rectal Bleeding Yellowing Skin DENIES ALL CARDIOVASCULAR Ankle Swelling Calf Cramping Cardiovascular Problems Cold Feet Murmur Elevated Blood Pressure Pacemaker Varicose Veins DENIES ALL CONSTITUTIONAL Anxiety Dizziness Fever Headaches Nausea/Vomiting Increased Thirst Tiredness Vertigo Weight Gain Weight Loss DENIES ALL GENITOURINARY Kidney Disease Currently Pregnant Urinary Frequency DENIES ALL IMMUNOLOGIC Arthritic Flare-Up Gout Hepatitis Seasonal Allergies DENIES ALL EYES Wears Glasses Blurred Vision Dry Eyes Loss of Vision DENIES ALL ENT Cough Difficulty Hearing Difficulty Swallowing Dry Mouth DENIES ALL ENDOCRINE Dry Hair Dry Skin Extreme Thirst Unusual Fatigue DENIES ALL PSYCHIATRIC Addiction to Alcohol Addiction to Drugs Anxiousness Depression Memory Loss Panic Attacks Emotional/Psychiatric Difficulties DENIES ALL RESPIRATORY Difficulty Breathing Shortness of Breath Wheezing DENIES ALL Page 3

4 TUBERCULOSIS (TB) SCREENING Due to OSHA (Occupational Safety and Health Administration) and CDC (Center for Disease Control) guidelines, we are required to have all new and established patients fill out a TB screening questionnaire annually. Have you ever had a positive TB test? Y N Do you currently have TB? Y N If yes, when? Date of last chest X-ray: Have you come in contact with any persons who have had TB within the last 30 days? Y Please indicate if you have had any of the following problems for 3 to 4 weeks or longer: Cough Phlegm/Bloody Phlegm Weight Loss Tiredness Night Sweats Breathing Difficulty N HIPAA/MEDICAL RECORDS - We are committed to protecting the security and privacy of your personal information. Medical records are the property of BRFAA, kept in a secure location, and are accessed for only purposes outlined by the Notice of Privacy Practices (copy available upon request). Records may be released or shared with other health care providers for your treatment. Patients are entitled to one free copy of their medical records only AFTER an authorization for release of medical information is signed. Additional copies may be made for a fee. BRFAA Policies & Procedures List any other person(s) that we may release your medical information to: COMMUNICATION POLICY BRFAA has permission to call and/or text your home, cell, and place of employment for healthcare reasons, appointment reminders, or to resolve billing issues. In addition, we may mail informational postcards to your home as well as billing statements and medical information. BRFAA may leave messages on your answering machine regarding appointments and limited lab information. We may also use your address to send updates about our office, billing statements, and appointment reminders. If you would like to opt-out of any of the above methods of communication, please advise one of our team members. PROVIDER POLICY - In the course of your treatment with BRFAA, you may see either: Dr. Paul Krestik, Dr. Heather Jones, or Daniel Albertson, APRN. If you have a preference of provider, please notify our office staff and we will make every effort to accommodate your preference. Page 4

5 BRFAA Policies & Procedures (continued) RETURN CHECK POLICY ALL returned checks are immediately sent to the county attorney s office who will charge a $50 fee for us plus the cost of the check in addition to a $50 fee for the county attorney s office. They will give you 10 days to pay in full or a bench warrant will be issued for your arrest. OUTSTANDING CHARGES Balances owed over 30 days may be charged a $20 late fee for every 30 days that the payment remains overdue. If your bill remains overdue greater than 90 days, it may be turned over to an outside collection agency at which point a $20 collection fee will be added and then the bill will be out of our hands. Arrangements must be made to repay the bill through the collection agency. All outstanding bills must be settled PRIOR to receiving care, unless arrangements have been made with our office. We will make every attempt to help you. CANCELLATIONS/MISSED APPOINTMENTS - Failure to keep your appointment or failure to cancel your appointment without reasonable notification may result in a penalty fee of $25. This fee is NOT covered by insurance and is the sole responsibility of the patient and will be billed accordingly. Repeat offenders may be discharged from our office at the providers discretion. Please have the courtesy and respect to call our office for all appointments that cannot be kept. I certify that the medical information that I have included on the previous forms is true and correct to the best of my knowledge. I give permission to Bluegrass Regional Foot and Ankle Associates to administer and perform such procedures as may be deemed necessary for diagnosis and/or treatment. These policies have been established to help us continue to provide you with the best quality of medical care. If you have any questions or concerns about these policies, please ask the Office Manager. I have read and understand the above policies and agree to abide by the guidelines. Print Name: Date: Patient/Guardian Signature: Page 5

6 BRFAA Payment Agreement PAYMENT IS DUE AT THE TIME OF SERVICE - Co-pays, deductibles, co-insurances/percentages, noncovered charges, and self-pay services are due on date of service. If you are unable to pay today, please let the receptionist know and we will be happy to reschedule your appointment for a future date. We have verified your insurance benefits prior to being seen, but please note this is only an ESTIMATE and not a guarantee. We are not responsible for any misinformation from the insurance company. Your insurance is a contract between you and the insurance company. Our office CANNOT guarantee that your insurance carrier will pay your claim. If your claim is denied by your carrier, the obligation for payment is the responsibility of the patient. If you wish to contest any denied service or procedure, it is your responsibility to discuss that with your insurance. We will, however, be happy to assist wherever possible. Any changes to your demographics or insurance must be brought to our attention BEFORE being seen. Failure to do so may result in the patient being responsible in FULL for all charges of services rendered. By signing the bottom of this page, you give us permission to bill your insurance and to release to them all information necessary to secure payment. In addition, you are agreeing to be responsible for all charges not covered by your insurance or charges your insurance deems your responsibility including any self-pay services. FINANCIAL OBLIGATION (to be filled out by BRFAA employee & explained to you, the patient) Medicare ONLY $ deductible, $ remains, 20% co-insurance after deductible is met. Medicare with a secondary / supplemental insurance Your secondary WILL WILL NOT WILL CONSIDER TO cover your Medicare deductible. Your secondary WILL WILL NOT WILL CONSIDER TO cover your Medicare 20% co-ins. Co-pay of $ per visit. Co-insurance of %. Multiple insurance carriers: We will submit to both insurances and you will be responsible for any outstanding balance after both insurance carriers process your claim. Claim Submission We will submit claim to your insurance. You will be responsible for any balance after they pay. Deductible has not been met. $ deductible, $ remains; responsible for % co-insurance once met. Self-pay / No insurance I have read and understand the payment policy and my financial obligation and agree to abide by them. Print Name: Date: Patient/Guardian Signature: Page 6