We look forward to meeting you, and will be available for you at any time. Dr. Douglas Scott, M.D. Dr. Kirk Johnson, M.D.

Transcription

1 Welcome to Orthopedic Associates of the Lowcountry. Thank you for your confidence in allowing us to help care for your health. It is a responsibility we respect, and take very seriously. Please take the time to complete the following forms, which help our team effectively coordinate your care. Please fill in the medication list completely. We look forward to meeting you, and will be available for you at any time. Dr. Douglas Scott, M.D. Dr. Kirk Johnson, M.D. Tom Thomas, PA-C

2 DATE: ORTHOPEDIC ASSOCIATES OF THE LOWCOUNTRY Patient Registration Form (Please Print Clearly) Patients Full Name: (LAST) (FIRST) (MIDDLE) (MAIDEN) Date of Birth: Social Security #: Marital Status: S M W D Address: City: State: Zip Code: Home Phone #: Cell Phone #: Other: address: *Race: *Language of Preference: * Ethnicity: *FOR DEMOGRAPHIC PURPOSE ONLY Employer: Phone: Address: Spouse s Name: Date of Birth: SS#: Family Physician: Address: Referring Physician: Address: Reason for visit: / LT, RT, Both Is office visit due to an injury? YES or NO / Date of Injury: Nature of injury: Is injury due to a recent auto accident? YES or NO / Date of accident: Emergency Contact Name: Phone: COMPLETE BELOW FOR PATIENTS UNDER 18 AND/OR COVERED BY PARENTS INSURANCE Fathers Name: Date of Birth: SS#: Address (if different than child): Home phone #: Employer: Work ph. #: Mothers Name: Date of Birth: SS#: Address (if different than child): Home phone#: Employer: Work ph. #:

3 Patient History Form (Please Print Clearly) Current Medications, MG s & frequencies taken: (SEE ATTACHED LIST) Any allergies to medications: List surgeries with the approximate dates: PHARMACY: ADDRESS: PAST & PRESENT MEDICAL HISTORY (Check all that apply) AIDS/HIV Cerebrovascular Accident DVT Kidney Disease A - FIB Congestive Heart Failure Fibromyalgia Liver Disease Alcoholism COPD GERD Myocardial Infarction Asthma Coronary artery disease Gout Osteoarthritis Cancer(Type) Depression Hepatitis Renal Disease Cholesterol Diabetes Hypertension Rheumatoid Arthritis Sleep Apnea Thyroid Disease Other ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING (Check all that apply) Abnormal bleeding Depression Palpitation Anxiety Diarrhea Rash / Skin problems Constipation Easy Bruising Shortness of Breath Cough Fatigue Ulcers FAMILY HISTORY (Please check) Cancer (Type) Heart Disease High Cholesterol Depression High Blood Pressure Stroke Diabetes Other SOCIAL HISTORY (Check all that apply) Caffeine Intake: (Circle) TEA COFFEE SODA How many cups per day Alcohol Intake: (Circle) LIQUOR BEER WINE How many drinks (Daily - Weekly) Smoke: (Circle) YES or NO Number of packs a day If former smoker, year quit PATIENT SIGNATURE: DATE:

4 OFFICE FINANCIAL POLICY Patients are financially responsible for all services provided and are expected to pay for services received on the same date that services are rendered. Patients are also responsible for any past due balance from a prior date of service. If the patient is a minor child, the parent or other adult accompanying the child will be financially responsible regardless of legal guardianship. MEDICARE: The office will bill the Medicare intermediary. Patients are responsible for the following: Annual Medicare Part B deductible 20% co-pay of the allowed charge Any non-covered services Any covered service ordered by the physician which does not meet Medicare s medical necessity and for which the beneficiary signed an Advanced Beneficiary Notice (ABN) MEDICARE SUPPLEMENT: The office will bill both Medicare & Secondary Insurances. MEDICAID: Medicaid patients are to provide the clinic with a current Medicaid card with every visit. Medicaid patients are responsible for all non-covered services & all applicable co-pays. Medicaid patients are responsible for securing necessary referrals from primary care physicians. HMO S and PPO S: Patients are responsible for payment of the co-pay & deductible at the time of service as well as for any charges for which the patient failed to secure prior authorization, if authorization is necessary. If the patient is not prepared to pay the co-pay or deductible, the medical assistant or nurse will determine if it is medically necessary for the patient to see the physician. If the patient s condition allows, the appointment will be rescheduled. COMMERCIAL INSURANCE: Patients are responsible for any co-pay, deductible, or non-covered amounts. Insurance is billed as a courtesy. If the patient is not prepared to pay the co-pay or deductible, the medical assistant or nurse will determine if it is medically necessary for the patient to see the physician. If the patient s condition allows, the appointment will be rescheduled. SELF PAY: Patients are responsible for payment in full at the time of service for all services rendered. WORKERS COMPENSATION: Patients are NOT responsible for any charges unless the workers compensation case has been dismissed or denied. PERSONAL INJURY / MOTOR VEHICLE ACCIDENTS: The patient is responsible for the balance in full at the time of service. Any settlement you receive from your insurance company will be handled by you, your insurance company, and / or your attorney. MANAGED CARE: If the patient presents an out of state HMO / PPO insurance card, we will need to verify the patient s benefits for out-of-state or out-of-network benefits. The patient will either be required to make payment in full or pay any co-pay or deductible. I understand the above policy and acknowledge that I am financially responsible for the services rendered. PATIENT or PARENT / GUARDIAN: DATE:

5 PERMISSION TO BILL & RELEASE INFORMATION TO INSURANCE PROVIDER I, the undersigned, assign directly to Orthopedic Associates of the Lowcountry all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the office to release all information to secure the payment of benefits. I authorize the use of my signature on all insurance submissions whether manual or electronic. I further authorize Orthopedic Associates of the Lowcountry to disclose information in my medical records, including current and previous medical records, to other physicians and health care providers to whom the physician refers me for my treatment. Financial Agreement I acknowledge that payment is due at time of treatment and I agree that Parents / Guardians are responsible for all fees and services rendered for treatment of a minor / child. I accept full responsibility for all charges not covered by insurance. Signature: Date: Print name: Relationship to patient: MINOR CHILD CONSENT I, being the parent / guardian of do hereby request and authorize Orthopedic Associates of the Lowcountry and staff to perform necessary services for my child, including but not limited to x-rays, labs and administration of medications and anesthetics which are deemed advisable by the physician. Signature: Date: Print name: Relationship to patient:

6 Patient Registration Form Insurance Information: Complete only if you do NOT have a current copy of your insurance card & be sure to notify us if your insurance has changed. Policy Holder s Name: Policy Holder s Date of Birth How did you hear about us? (Please check all the apply) Family/Friend Physician Patient Work Insurance Yellow Pages Hospital Radio Mail Newspaper NOTICE OF PRIVACY PRACTICES (NPP) ACKNOWLEDGEMENT A Notice of Privacy Practices (NPP) is provided to all patients. This Notice of Privacy Practices identifies: 1) how medical information about you may be used or disclosed; 2) your rights to access your medical information, amend your medical information, request an accounting of disclosures of your medical information, and request additional restrictions on our uses and disclosures of that information; 3) your rights to complain if you believe your privacy rights have been violated; and 4) our responsibilities for maintaining the privacy of your medical information. The undersigned certifies that he/she has read the foregoing, received a copy of the Notice of Privacy Practices and is the patient, or the patient s personal representative. Signature of Patient: Date: Please list anyone in your family, or other than yourself, that we may disclose your PHI or appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. Your PHI may be disclosed to the person(s) below: Authorized Person Relationship to Patient Date