Premier Prosthetic



PATIENT INFORMATION FORM (PLEASE PRINT) DATE: MERGEFIELD "CurrentDate" ?CurrentDate? TIME: MERGEFIELD "CurrentTime" ?CurrentTime?PATIENT INFORMATIONSocial Security No. MERGEFIELD "PatientSSN" ?PatientSSN? Patient Name MERGEFIELD "PatientFullName" ?PatientFullName?Sex: MERGEFIELD "PatientSex" ?PatientSex? Date of Birth MERGEFIELD "PatientDOB" ?PatientDOB? Marital Status: Single, Married, Divorced, Widowed, Legally Separated (circle one) Race: Caucasian/White, Latino/Hispanic, Black or African American, American Indian or Alaskan Native, Asian, Native Hawaiian or Other Pacific Islander, Other, Not Reported/Refused (circle one) Ethnicity: Caucasian/White, Latino/Hispanic, Black or African American, Other, Not Reported/Refused (circle one)Language: English, French, Spanish, Chinese, Japanese, Korean, Sign Language, Vietnamese, Other (circle one) Employment Status: Employed, Unemployed, Self Employed, Disabled, Retired, Full-time Student, Part-time Student (circle one) Employer: ________________________ Occupation _____________________________________Patient Mailing Address _____________________________________ City ___________________ State _____ Zip __________ E-mail Address ___________________________________________ Home Phone ___________________________ Cell Phone _________________________ Work Phone _____________________ Referring Physician (Include Phone No.) _______________ By including your cell phone number, you have given Premier consent to call your cell phone for appointment reminders using our automated system.Other Current Healthcare Providers (Include Phone No.) Primary Care ____________________Cardiology ____________________________ Pulmonary _____________________ Endocrinology ___________________________ Nephrology _____________________ Dialysis Center ___________________________ INSURANCE INFORMATION PRIMARY Insurance Company _______________ Group No. ___________ Member ID _________Specialist Office Co-pay Amount _______ Subscriber's Social Security No. __________________ Primary Insurance Subscriber: Patient, Other (circle one) Subscribers Name (First, Middle, Last) ________________________________ Sex: M F (circle one) Date of Birth __________________________ Marital Status: Single, Married, Divorced, Widowed, Legally Separated (circle one) Employment Status: Employed, Unemployed, Self Employed, Disabled, Retired, Full-time Student, Part-time Student (circle one) age 1 of 5 08/2010 PATIENT INFORMATION FORM, CONTINUED MERGEFIELD "PatientFullName" ?PatientFullName? MERGEFIELD "PatientNumber" ?PatientNumber?Subscribers Employer _________________________________________________ Subscribers address (if different from patient) _______________________________ City ____________State ____ Zip _______ Subscribers Home Phone _____________ Cell Phone ____________ Work Phone ____________ Patient Relationship to Subscriber: Self, Child, Wife, Husband, Parent, Other (circle one) SECONDARY Insurance Company ______________________ Group No. ____________ Member ID _____________________ Specialist Office Co-pay Amount _______ Subscriber's Social Security No. __________________ Secondary Insurance Subscriber: Patient Other (circle one) Subscribers Name (First, Middle, Last) ________________________________ Sex M F (circle one) Subscriber's Date of Birth ________________ Marital Status: Single, Married, Divorced, Widowed, Legally Separated (circle one) Employment Status: Employed, Unemployed, Self Employed, Disabled, Retired, Full-time Student, Part-time Student (circle one) Subscribers Employer __________________________ Subscribers address (if different from patient) _______________________________ City ____________State ____ Zip _______ Home Phone _______________ Cell Phone _______________ Work Phone _______________ Patient Relationship to Subscriber: Self, Child, Wife, Husband, Parent, Other (circle one) WORKERS COMPENSATION or AUTO INSURANCE INFORMATION Your Supervisor ________________________ Supervisors Phone No. _______________________ Workers Compensation or Auto Insurance Phone No. __________________________________ Claims Address ____________________ City _______________ State ______ Zip _____________ Adjusters Name ______________________ Adjusters Phone No. __________________________ Claim No. _________________ Approval No. __________________________________________ Date of Injury ____________ Did injury occur at work: Y N (circle one) Auto Accident: Y N (circle one) Briefly describe injury or accident ______________________________________________________________________________ Page 2 of 5 08/2010 NEW PATIENT INFORMATION FORM, CONTINUED EMERGENCY CONTACT INFORMATION MERGEFIELD "PatientFullName" ?PatientFullName? MERGEFIELD "PatientNumber" ?PatientNumber?Contact Name (First, Middle, Last) ___________________________________ Sex: M F (circle one) Language: English, French, Spanish, Chinese, Japanese, Korean, Sign Language, Vietnamese, Other (circle one) Home Phone _____________ Cell Phone _______________ Work Phone ____________________ Patient Relationship to Contact: Child, Wife, Husband, Parent, Grandparent, Other (circle one) Contact is a Parent/Guardian: Y N (circle one) If patient is under the age of 18, Emergency Contact should be a Parent or Guardian unless patient is an Emancipated Minor. PHARMACY Patient's Preferred Pharmacy _____________________ Phone No. ________________________ Pharmacy Address ___________________ City ______________ State ____ Zip _______________ CONSENTS Do you have any of the following: Living Will, Do Not Resuscitate (DNR), Power of Attorney, End of Life Decision, No Cardio-Pulmonary Resuscitation (CPR), None (circle any that apply) List names of anyone you give us permission to release your medical information to, their relationship to you and phone no. _______________________________________________________________________________ _______________________________________________________________________________ May we leave a message for you on your phone at: home, work, cell (circle all that apply) Page 3 of 5 08/2010 PATIENT HISTORY MERGEFIELD "PatientFullName" ?PatientFullName? MERGEFIELD "PatientAge" ?PatientAge? MERGEFIELD "PatientDOB" ?PatientDOB?Reason for visit:________________________________________________ Patient Past Medical History FORMCHECKBOX No Prior Serious IllnessMusculoskeletalEndocrine FORMCHECKBOX Y FORMCHECKBOX N Arthritis FORMCHECKBOX Y FORMCHECKBOX N Diabetes FORMCHECKBOX Y FORMCHECKBOX N Gout FORMCHECKBOX Y FORMCHECKBOX N Thyroid Disorders FORMCHECKBOX Y FORMCHECKBOX N Lupus FORMCHECKBOX Y FORMCHECKBOX N Hyperlipidemia (High Cholesterol) FORMCHECKBOX Y FORMCHECKBOX N FibromyalgiaEyesBreast FORMCHECKBOX Y FORMCHECKBOX N Glaucoma FORMCHECKBOX Y FORMCHECKBOX N Breast Cancer FORMCHECKBOX Y FORMCHECKBOX N Legally Blind FORMCHECKBOX Y FORMCHECKBOX N Skin Cancer FORMCHECKBOX Y FORMCHECKBOX N SclerodermaCardiovascular FORMCHECKBOX Y FORMCHECKBOX N High Blood PressureNeurologic FORMCHECKBOX Y FORMCHECKBOX N Congestive Heart Failure FORMCHECKBOX Y FORMCHECKBOX N Stroke FORMCHECKBOX Y FORMCHECKBOX N Prior Heart Attack FORMCHECKBOX Y FORMCHECKBOX N Seizure Disorder, Epilepsy FORMCHECKBOX Y FORMCHECKBOX N Cardiac Catherization FORMCHECKBOX Y FORMCHECKBOX N Brain Aneurysm FORMCHECKBOX Y FORMCHECKBOX N Coronary Artery Disease FORMCHECKBOX Y FORMCHECKBOX N Neuroloathy (Weakness in hands/feet) FORMCHECKBOX Y FORMCHECKBOX N Previous Hospitalization for Cardiac Problem FORMCHECKBOX Y FORMCHECKBOX N Non healing woundHematologic/LymphRespiratory FORMCHECKBOX Y FORMCHECKBOX N Blood Clots FORMCHECKBOX Y FORMCHECKBOX N Asthma FORMCHECKBOX Y FORMCHECKBOX N Anemia FORMCHECKBOX Y FORMCHECKBOX N Emphysema FORMCHECKBOX Y FORMCHECKBOX N HIV Infection FORMCHECKBOX Y FORMCHECKBOX N Bronchitis FORMCHECKBOX Y FORMCHECKBOX N Hodgkin’s Disease FORMCHECKBOX Y FORMCHECKBOX N Pneumonia FORMCHECKBOX Y FORMCHECKBOX N Leukemia FORMCHECKBOX Y FORMCHECKBOX N Tuberculosis FORMCHECKBOX Y FORMCHECKBOX N Lymphoma FORMCHECKBOX Y FORMCHECKBOX N Shortness of breath FORMCHECKBOX Y FORMCHECKBOX N Sleep ApneaSocial HistoryGI FORMCHECKBOX Y FORMCHECKBOX N Alcohol Use Frequency____ FORMCHECKBOX Y FORMCHECKBOX N Diverticulitis of Colon (Inflamed Colon) FORMCHECKBOX Y FORMCHECKBOX N Caffeine Use FORMCHECKBOX Y FORMCHECKBOX N Colonic Diverticulosis FORMCHECKBOX Y FORMCHECKBOX N Drug Use FORMCHECKBOX Y FORMCHECKBOX N Gastroesophageal reflux disease (GERD) FORMCHECKBOX Y Current every day smoker FORMCHECKBOX Y FORMCHECKBOX N Colon Cancer FORMCHECKBOX Y Current some day smoker FORMCHECKBOX Y FORMCHECKBOX N Hepatitis FORMCHECKBOX Y Former Smoker FORMCHECKBOX Y FORMCHECKBOX N Ulcerative Colitis FORMCHECKBOX Y Never smoked FORMCHECKBOX Y FORMCHECKBOX N Crohn’s Disease FORMCHECKBOX Y Smoker, current status unknown FORMCHECKBOX Y FORMCHECKBOX N Cirrhosis FORMCHECKBOX Y Unknown if ever smoked FORMCHECKBOX Y FORMCHECKBOX N Hiatal Hernia FORMCHECKBOX Y FORMCHECKBOX N Tobacco Use FORMCHECKBOX Y FORMCHECKBOX N Irritable Bowel SyndromeFamily HistoryGU FORMCHECKBOX Y FORMCHECKBOX N Heart Disease FORMCHECKBOX Y FORMCHECKBOX N Kidney Stones FORMCHECKBOX Y FORMCHECKBOX N High Blood Pressure FORMCHECKBOX Y FORMCHECKBOX N Prostate Trouble FORMCHECKBOX Y FORMCHECKBOX N Diabetes FORMCHECKBOX Y FORMCHECKBOX N Dialysis FORMCHECKBOX Y FORMCHECKBOX N Stroke FORMCHECKBOX Y FORMCHECKBOX N Kidney Failure FORMCHECKBOX Y FORMCHECKBOX N Colon Cancer FORMCHECKBOX Y FORMCHECKBOX N End Stage Kidney Disease FORMCHECKBOX Y FORMCHECKBOX N Breast Cancer FORMCHECKBOX Y FORMCHECKBOX N Renal dialysis status hemodialysisPast Surgical HistoryGIArterial FORMCHECKBOX Y FORMCHECKBOX N Appendectomy FORMCHECKBOX Y FORMCHECKBOX N Aneurysm Repair (AAA) FORMCHECKBOX Y FORMCHECKBOX N Gallbladder Surgery FORMCHECKBOX Y FORMCHECKBOX N Previous Coronary Artery Bypass FORMCHECKBOX Y FORMCHECKBOX N Partial Colectomy (Colon Resection) FORMCHECKBOX Y FORMCHECKBOX N Leg Bypass FORMCHECKBOX Y FORMCHECKBOX N Colostomy (Ostomy Bag) FORMCHECKBOX Y FORMCHECKBOX N Peripheral Stent (Leg or Trunk Stent) FORMCHECKBOX Y FORMCHECKBOX N Ileostomy (Intestine) FORMCHECKBOX Y FORMCHECKBOX N HemorrhoidectomyMusculoskeletal FORMCHECKBOX Y FORMCHECKBOX N Small Bowel Resection FORMCHECKBOX Y FORMCHECKBOX N Back Surgery FORMCHECKBOX Y FORMCHECKBOX N Splenectomy FORMCHECKBOX Y FORMCHECKBOX N Hip Replacement FORMCHECKBOX Y FORMCHECKBOX N Pancreatectomy FORMCHECKBOX Y FORMCHECKBOX N Knee Replacement FORMCHECKBOX Y FORMCHECKBOX N Ulcer Surgery FORMCHECKBOX Y FORMCHECKBOX N Rotator Cuff Repair FORMCHECKBOX Y FORMCHECKBOX N Previous History of FractureHead and Neck FORMCHECKBOX Y FORMCHECKBOX N Thyroid SurgeryCardiac/Thoracic FORMCHECKBOX Y FORMCHECKBOX N Parathyroid Surgery FORMCHECKBOX Y FORMCHECKBOX N Heart Valve Replacement FORMCHECKBOX Y FORMCHECKBOX N Cardiac PacemakerFemale FORMCHECKBOX Y FORMCHECKBOX N Cardioverter-Defibrillator FORMCHECKBOX Y FORMCHECKBOX N Breast Surgery FORMCHECKBOX Y FORMCHECKBOX N Heart Stent Placement FORMCHECKBOX Y FORMCHECKBOX N Hysterectomy FORMCHECKBOX Y FORMCHECKBOX N Lung Surgery FORMCHECKBOX Y FORMCHECKBOX N Tubal Ligation FORMCHECKBOX Y FORMCHECKBOX N Cesarean SectionGU FORMCHECKBOX Y FORMCHECKBOX N Nephrectomy (Kidney) FORMCHECKBOX Y FORMCHECKBOX N Lithotripsy (Kidney Stones)Other FORMCHECKBOX Y FORMCHECKBOX N Prostate Surgery FORMCHECKBOX Y FORMCHECKBOX N Craniotomy FORMCHECKBOX Y FORMCHECKBOX N Temporal Artery BiopsyHernia FORMCHECKBOX Y FORMCHECKBOX N Cataract Surgery FORMCHECKBOX Y FORMCHECKBOX N Inguinal Hernia Repair (Groin) FORMCHECKBOX Y FORMCHECKBOX N Umbillical Hernia Repair (Navel) FORMCHECKBOX Y FORMCHECKBOX N Femoral Hernia Repair FORMCHECKBOX Y FORMCHECKBOX N Incisional Hernia Repair FORMCHECKBOX Y FORMCHECKBOX N Ventral Hernia Repair (Abdominal Wall)REVIEW OF SYSTEMSConstitutionalYESNOMuskuloskeletal SymptomsYESNO Recent Weight Gain ___ lbs Leg Pain with ExerciseRecent Weight Loss ___ lbs Lower Leg Swelling Fever (as symptom)PsychiatricEyes Depression Pain in or around the eyes Anxiety Vision Problems Memory Lapses or LossENMTSkin/Breast Hearing loss Breast Lump Bleeding Gums Breast PainCardiovascular Skin Lesions Chest Pain or Discomfort Skin Rash Fast Heart RateNeurologicRespiratory Dizziness Cough Confusion Shortness of BreathHematologic/LymphGI Easy Bleeding Black or Bloody Stools Easy Bruising Jaundice Swollen Glands in Neck Nausea Groin Lymph Node Swelling VomitingOther Constipation Possible Pregnancy Diarrhea Sleep Apnea Abdominal Pain GERDGU Blood in Urine Urinary Frequency Pain During UrinationHave you been prescribed a narcotic medication/pain medication from another physician in the last 30 days?_____Yes _____NoList current MedicationsName of DrugDosage (mg, tsp, etc.)How often do you take this medicineList any known AllergiesName of DrugType of Allergy/IntoleranceNOTICE OF PRIVACY PRACTICES ACKNOWLEDGED I have been given an opportunity to review, ask questions about and understand Premier Surgical Associates' Notice of Privacy Practices for Protected Health Information (Notice). Patient or Guardian's Signature __________________________ Date ________________________ PREMIER SURGICAL ASSOCIATES, PLLC PLEASE READ All charges are due at the time of service. If hospitalization or surgery is indicated, we will file your claim directly to your insurance company. Please remember that most insurance companies do not pay the full amount, and therefore, you are responsible for the balance. If there is a problem paying the balance in full, please let us know and we will be happy to work with you. FINANCIAL RESPONSIBILITY I understand and commit to the following: 1. I have received a copy of Premier's financial policies and have read and understand these policies. 2. I will pay my co-pay, deductible and co-insurance at the time of service. 3. I will provide the most current insurance information and immediately notify Premier of changes. 4. If surgery is required, all or a portion of my financial responsibility must be paid prior to surgery. 5. I will follow my insurance company's requirements for referrals and pre-authorizations and I understand that if I fail to do so, my insurance benefits will be reduced and I will be responsible for all denied balances. 6. I understand that I am responsible for all balances after insurance has paid. 7. If I have no insurance, I have informed Premier and I am responsible for 100% of all balances. 8. A collection fee of 30% will be added to all my accounts that are turned over to collection agencies. Patient's Signature__________________________ Date__________________________________ INSURANCE AUTHORIZATION AND RELEASE I request that payment of authorized benefits - including Medicare, and any other government sponsored program, private insurance, and any other health plans - be made to Premier Surgical Associates, PLLC for any services furnished by that provider. I authorize any holder of medical information about me to release to those persons or companies presenting a legitimate request for such information needed to determine these benefits or the benefits payable for related services. I authorize Premier Surgical Associates, PLLC to act as my agent to help me obtain any required pre-certification as well as acting as my agent to help me obtain payment from my insurance companies. I authorize my insurance companies to give Premier Surgical Associates, PLLC any information they require to fulfill this function. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the original. Patient's Signature __________________________ Date__________________________________ Page 4 of 5 08/2010 MEDICAL RECORDS RELEASE I hereby authorize Premier Surgical Associates, PLLC to release any information in my chart to any medical practitioner, doctor, hospital, medical institution to whom I may be referred to assist with my care. Additionally, I authorize any request for medical information from any medical practitioner, doctor, hospital, medical institution assist in my care. Patient's Signature __________________________ Date__________________________________ FOR MEDICARE SUPPLEMENT POLICIES ONLY ONE-TIME MEDIGAP ASSIGNMENT AND RELEASE _____________________________ __________________________________________________ Name Medicare Number ______________________________ __________________________________________________ Medigap Policy Name Medigap Policy Number ___________________________I request that payment of the authorized Medigap benefits be made on my behalf to Premier Surgical Associates, PLLC for services furnished to me by them. I authorize any holder of medical information about me to release it to: __________________________________________________________________________________ Name of Policy _________________________any information needed to determine these benefits or the benefits payable for related services. This will remain in effect until revoked in writing. A photocopy of this assignment and release is to be considered as valid as the original. Patient's Signature __________________________ Date__________________________________ Page 5 of 5 08/2010 ................
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