Jamie Gottlieb, M.D. Spinal Surgery PATIENT INFORMATION

Transcription

1 Jamie Gottlieb, M.D. Spinal Surgery PATIENT INFORMATION Patient name (please print) Date Date of birth Age Gender: Male Female We know that filling out these forms can be difficult, but please complete them carefully. Your accurate responses will give us a better understanding of you and your problem. From this information, we can provide you with the best medical care possible. Please help us, and yourself, by taking the time required to answer the questions accurately. Be careful to follow the directions in each sentence. Clearly mark the check boxes, circle the appropriate response, or write legibly where indicated. Thank you for your cooperation! A

2 HIPPA NOTICE OF PRIVACY PRACTICES Dr. Jamie Gottlieb We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer in person or by phone at our main phone number. Please return this signed form to the front desk to be placed in your patient file. Print Name Signature Date STANDARD AUTHORIZATION OF USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION Information regarding my medical condition may be disclosed to: Name Relationship Phone Number Expiration Date of Authorization This authorization is effective unless revoked or terminated by the patient or the patient s personal representative. Right to Terminate or Revoke Authorization You may revoke or terminate this authorization by submitting a written revocation to Dr. Jamie Gottlieb. Permission to Leave Message Authorization for information regarding patient to be left by message to person or machine at designated phone number. Print Name Date Dr. Jamie Gottlieb is part owner of the Unity Surgery Center in Mishawaka, IN. The physician believes that any and all of their subsidiaries are appropriate settings for this medical care and services for which you are being referred. Nevertheless, the selection of a specific health care provider always rests with the patient, and you may choose to be referred to an alternate setting if you so desire. Print Name Signature Date 03/2014 B

3 I- Spine Institute 5218 Beck Drive Suites 9 & 10 Elkhart, IN We are pleased that you have chosen I- spine Institute for your healthcare. We are committed to providing you with the best possible care. We encourage you to discuss with us any concerns you have about our professional fees and financial policies. While we will make every attempt to assist you by filing insurance claims, payment for services is your responsibility. HMO/PPO If your insurance is a HMO/PPO plan, co- pays must be made at the time services are rendered. Referral forms are the patient s responsibility and must be obtained prior to your appointment from your primary care physician. Medicare We accept Medicare assignment and will file your supplemental insurance. Medicaid We are not Medicaid providers. Please contact the office immediately if you have a scheduled appointment and have Medicaid. Worker s Compensation We will submit claims to your employer or their insurance carrier for work- related injuries. In order to do this, we must have authorization from the employer, an accurate billing address, and a contact person s name and phone number. Other Insurance/Out of Network We will file claims as a courtesy to you. However, insurance coverage is a contract between you and your insurance company. Liability/MVA If you sustained injuries from a motor vehicle accident or other accident, you must provide us with complete insurance information including company name, phone number, billing address and contact person s name so we can file the claim for you. Attorney We do not bill attorneys. We expect payment at the time of service and consider the patient, not his attorney, to be financially responsible for the medical services received. In certain circumstances, we will accept a letter of protection. Treatment of Minors Although we will file claims with the appropriate insurance company, the adult accompanying a minor will be responsible for the medical services received. No Insurance We expect payment at the time of service. If this presents a financial hardship, please discuss this with our financial advisor so a payment arrangement can be made. Returned Checks A $25 fee will be imposed on all returned checks. I have read and understand this financial policy. NAME DATE C 12/2013

4 CONSENT TO TREAT Dr. Jamie Gottlieb Patient s Name Account # I understand that I require treatment in this facility because of my condition. I permit my physician(s) or his employees, students in training, all other persons caring for me to treat me in ways they judge are beneficial to me. I understand that this care may include tests, nursing care, examinations, and medical and surgical treatment. I recognize it is the responsibility of my physician to explain to me the nature of any diagnostic tests and medical and/or surgical procedures judged by him as necessary for my treatment and to advise me of risks and consequences of such procedures. I acknowledge that no guarantees have been made to me by my physician as to the result of any treatments, examinations, and/or operative procedures performed in the physician s office. Release of Medical Information I hereby authorize the physician involved with my care to release information from my medical record as may be required to any person, corporation, or agency which is legally responsible or has good cause to believe is legally responsible for processing and/or paying all or any part of the physician s charges and/or professional fees to which any entity designated by me for discharge and planning purposes. Medicare Consent (if applicable) I certify that the information given by me in applying for payment under title XVIII (Medicare) of the Social Security Act is correct. I authorize any holder of medical or other information about me to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medical Claim. I request that payment of authorized benefits may be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. The Medicare intermediary advises that the type of services may no longer qualify as covered under Medicare. Assignment of Benefits/Financial I hereby assign payment directly to I- Spine Institute all insurance benefit payments (including any major medical payments) due to me as a result of the named patient s outpatient treatment or service and pursuant to any insurance contract I have which provides for such treatment. I agree to be responsible for any charges incurred that are not paid by insurance or other third party payers. By signing this document, I acknowledge that I have read and understand this consent. Further, I hereby consent and authorize this facility to use or disclose my Protected Health Information in conjunction with Treatment, Payment or Health Care Operations in accordance with the terms of consent. Patient Signature Responsible Person/Legal Guardian Signature Date Printed Name & Relationship of Person Above D 12/2013

5 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT Dr. Jamie Gottlieb I understand that, under the Health Insurance Portability & Accountability Act of 1996 ( HIPPA ), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan, and direct my treatment and follow- up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third- party payers. Conduct normal healthcare operations, such as quality assessments and physician certifications. I have received, read, and understand your Notice of Privacy Practices (NPP), containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change is NPP from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the NPP. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree than you are bound to abide by such restrictions. Client Name (please print) Relationship to Client Signature Date OFFICE USE ONLY I attempted to obtain the client s signature in acknowledgment on this NPP Acknowledgment, but I was unable to do so as documented below: Individual refused to sign Communication barriers prohibited obtaining the acknowledgment An emergency situation prevented me from obtaining acknowledgment Other (please specify) Date Initials 3/2014 E

6 CONSENT TO PHOTOGRAPHY PATIENT NAME I hereby consent to the taking of photographs (still photo or videotape) or myself while a patient at the I- Spine Institute LLC located in Elkhart, Mishawaka or Plymouth, Indiana; for the following purposes(s): CHART IDENTIFICATION ONLY I hereby hold the i- Spine Institute LLC free and harmless from any and all liability arising out of the use of these photographs (still or videotape). Patient or Legal Guardian Signature Date Relationship to Patient Witness Signature 03/2014 F

7 NEW PRESCRIPTION POLICY Effective 12/15/2013 As of December 15, 2013, we have a new prescription policy. We understand that this is a change for both you and us. We hope to work together to ensure safe and high quality medical care. Due to the new Indiana State Law, LSA Document #13-495(E), all patient maintaining on opiod medications will be referred to pain management. Dr. Gottlieb will only manage pain medications perioperatively. Certain pain medications and other restricted substances cannot be called in. If you are a surgery patient and your medication falls into these categories, you will need to come in and pick up a written prescription. We do not fill prescriptions over the weekend and/or holidays. We would like you to request prescription refills at the time of your office visits. Refill requests will be accepted all day Monday, Tuesday, and Wednesday. All refill requests submitted after 12:00 p.m. on Thursday will be reviewed on the following Monday. Please allow 24 to 48 hours for prescriptions to be called in. If you call for a prescription refill, please have the following information available: Your name Your date of birth Medication name Medication dosage How you are taking the medication (once daily, twice daily, etc.) Quantity needed (one month, etc.) Pharmacy name and phone number Contact number where you can be reached DURING THE DAY (i.e. cell phone) if we have questions I have read and understood this prescription policy. Patient Signature Date: Revised 12/15/13 by MG G

8 MRI SCREENING FORM FOR PATIENTS Patient Name: Date: Weight: Age: Sex: This questionnaire is designed to assist us in determining if it is safe for you to undergo an MRI procedure. It is important that you answer all of the following questions. If you do not understand a question, please do not hesitate to ask for assistance. 1. Do you have a pacemaker, pacing wires, defibrillator, implanted heart valve, or stents? Yes No 2. Have you ever had any surgery on your Brain, Head, Ears, Eyes or Chest? Yes No 3. Do you have any kind of a Surgically- implanted Metallic, Mechanical, Magnetic or Electronic device inside of your body now? Yes No 4. Have you ever at any time in your life done ANY welding or grinding? Yes No 5. Have you EVER been injured by ANY metallic foreign body to either the eyes or body? Yes No 6. Do you have a hearing aid, middle/inner ear prosthesis, or removable dental work? Yes No 7. Do you have any permanent eyeliner, tattoos, or body piercing including ears? Yes No 8. Do you have any kind of medicine, pain, nicotine or nitroglycerin patch? Yes No 9. Is there any chance you might be pregnant, or are you currently breastfeeding? Yes No 10. Are you claustrophobic; have a fear of enclosed or narrow spaces? Yes No 11. Are you allergic to any medication, have a history of asthma, other allergic reactions, respiratory disease, or reaction to a contrast medium or dye used in MRI, CT or XRAY? Yes No 12. Have you had any tests for the symptoms that you are currently experiencing? Yes No If Yes, where was your test performed? 13. Have you EVER had ANY kind of surgical procedure? When? Yes No Please list ALL surgeries CURRENT SYMPTOMS: Please check any of the following current symptoms you are experiencing: Chest Pain Abdominal Pain Pelvic Pain Headaches Unexpected Weight Loss Back Pain Neck Pain Nausea Shoulder Pain (LT /RT ) Blackouts Blurred vision Dizziness Leg Pain (LT /RT ) Hearing Loss Ringing in ears Memory Loss Arm Pain (LT /RT ) Numbness (LT /RT ) Weakness (LT /RT ) Did any Accident or Injury occur to cause these symptoms? Yes No How long have these symptoms been occurring? MEDICAL HISTORY: 1. Have you ever been diagnosed with ANY type of cancer? Yes No If yes, what kind of cancer and when was the diagnosis: 2. Do you have or have you had any of the following: Seizures Diabetes Heart Disease High Blood Pressure Kidney Disease Stroke Asthma Bronchitis Emphysema COPD Non Cancerous Tumors, Lumps or Masses Any other Disease or Illness I certify that I have read and understand the questions asked in this questionnaire and that the above responses are correct to the best of my knowledge. I understand that it is my responsibility to inform the physician and the MRI facility of any metal fragments and/or devices that may be in my body and that by failing to do so may cause serious bodily injury or be life threatening. I agree that should I have any metal in my body and, after consultation with a physician, elect to proceed with an MRI, I agree to release the physician and the MRI facility from any and all liability for any injury. Patient or Legal Representative Signature Print Name and Authority (if legal representative) Date Witness of Interpreter Signature Print Name Date Witness of Interpreter Signature Print Name Date 3/2014 H