COMPREHENSIVE ORTHOPAEDIC HISTORY (PAGE1)
**NEW PATIENT INFORMATION FORM**
(Please print clearly)
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|Patient: _____________________________________________________________ |Today’s Date: _______________________ |
|Last Name First Name MI | |
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|If patient is a minor, Parent’s name(s): ______________________________ |Patient SS# _________________________ |
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| |Date of Birth: ________________________ |
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| |Age: __________ Sex: M F |
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|Address: ______________________________________________________________ | |
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|City: __________________________________State: ________ Zip: ___________ | |
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|Summer address: _____________________________________________________ |Marital Status: S M D W Sep |
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|Email: _________________________________________________________________ |Preferred method to contact: |
| |Phone Email Mail |
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|Hm Ph: _____________________________ Cell/Other:_____________________ |Wk Ph:_______________________________ |
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|Employer: ____________________________________________________________ |Occupation:_________________________ |
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|Referring physician: _________________________________________________ |Ph: __________________________________ |
|**INSURANCE INFORMATION** |
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|Primary Insurance: ___________________________________________________ |Name of Insured: ___________________ |
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|Relationship to Insured: Self Spouse Child Other |Insured D.O.B. ______________________ |
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|Insured SS#: __________________________________________________________ |Grp#__________________________________ |
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|Secondary Insurance: ________________________________________________ |Name of Insured:____________________ |
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|Relationship to Insured: Self Spouse Child Other |Insured D.O.B. ______________________ |
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|Insured ID #: _________________________________________________________ |Grp#_________________________________ |
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|Is the patient currently in a skilled nursing facility (SNF) ? |Yes No |
|If yes, name of facility? ______________________________________________ |Ph: __________________________________ |
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|Please list the name of the primary person to contact in case of emergency regarding your medical condition: |
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|Name: ____________________________________ Relationship: _____________ |Phone: _______________________________ |
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|Please list the name(s) of other family and/or friends that we may inform about your medical condition: |
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|Name: ____________________________________ Relationship: _____________ |Phone: _______________________________ |
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|This is an acknowledgement that the information provided is accurate to the best of my knowledge. |
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|__________________________________________________________ ___________________________________________________ |
|Patient or Designated Representative Signature Printed Name Date |
COMPREHENSIVE ORTHOPAEDIC HISTORY (PAGE1) Patient Name: ____________________
CHIEF COMPLAINT
Why are you seeing the doctor today? _______________________________________________________________
The current problem is the result of: (please circle all that apply) Auto Worker’s Comp. Other: __________________
LIST ANY AND ALL MEDICATIONS – NOT JUST ORTHOPEDIC RELATED MEDICATIONS
|Medication |Dose |Reason |Medication |Dose |Reason |
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DO YOU HAVE ANY ALLERGIES OR ADVERSE REACTIONS TO MEDICATIONS AND/OR SHELLFISH? YES NO
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Are all immunizations up to date? Yes No If no, which are due? _______________________________________
PAST MEDICAL HISTORY – LIST ALL MEDICAL HISTORY –SURGERY/HOSPITALIZATION/PROBLEMS
| |Year |Complications |
| | | |
| | | |
| | | |
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Have you ever had general anesthesia? Yes No If yes, any problems with anesthesia? Yes No
SOCIAL HISTORY
|□ Work in the home |□ Employed (occupation_____________________) |□ Student |□ Retired |
|□ Single |□ Married |□ Divorced |□ Separated |□ Widowed | |
|Do you have children? |Yes No |How many? 1 2 3 4 5 Other: ________ |
|Do you live alone? |Yes No |Exercise? |□ Daily |□ Weekly |□ Rarely |□ Never |
|Why type of exercise? |
|History of substance abuse? Yes No |What? |
|Smoke currently? | Yes No |____________packs per day for ____________ years |
|Quit smoking? |□ This year |□ > 1 yr |□ > 5 yrs |□ > 10 yrs- smoked __________packs per day for yrs |
|Drink alcohol? |□ Daily |□ 1- 2 x/wk |□ 1- 2 x/mo |□ 1- 2 x/year |□ No, I do not drink |
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|Are YOU or have YOU ever been a victim of domestic violence? Yes No |
Updated: ___/___/___; ___/___/___; ___/___/___; ___/___/___; ___/___/___; ___/___/___ ; ___/___/___ ; ___/___/___
COMPREHENSIVE ORTHOPAEDIC HISTORY (PAGE 2) Patient Name: _____________________
REVIEW OF SYSTEMS
Are you currently having or have you had problems with the following: Please describe all YES responses.
|YES |NO | |
| | |High blood pressure |
| | |High Cholesterol |
| | |Diabetes |
| | |Stomach ulcers |
| | |Heart attack |
| | |Chest pain/tightness |
| | |Heart disease, Heart Murmur, Abnormal Heartbeat |
| | |Stroke |
| | |Cancer- location: |
| | |Hepatitis/yellow jaundice |
| | |Glaucoma, cataract, eye disorder |
| | |HIV (AIDS virus) exposure |
| | |Seizure disorders/epilepsy |
| | |Bleeding disorders |
| | |Tuberculosis |
| | |Gall Stones |
| | |Kidney stones |
| | |Abdominal bleeding |
| | |Diverticulosis |
| | |Thyroid problem |
| | |Lung problem |
| | |Asthma |
| | |Shortness of breath |
| | |Numbness/tingling |
| | |Swelling of joints |
| | |Arthritis/rheumatism |
| | |Bowel/bladder problem |
| | |Gout |
| | |Circulation disorder |
| | |Nervous problem |
| | |Rheumatic fever |
| | |Depression |
FAMILY HISTORY
|Member |Alive(√) |Deceased(√) |Age |Please list health status or cause of death |
|Father | | | | |
|Mother | | | | |
|Sister/Brother | | | | |
|Sister/Brother | | | | |
| | | | | |
PATIENT SIGNATURE: __________________________________________ TODAY’S DATE: ___________________
***FOR OFFICE USE ONLY***
|Height | |Height | |Height | |Height | |
|Weight | |Weight | |Weight | |Weight | |
|BMI | |BMI | |BMI | |BMI | |
|Updated | |Updated | |Updated | |Updated | |
Reviewed by ____________MD Date: ___/___/___; Updated:___/___/___; ___/___/___; ___/___/___; ___/___/___
COORDINATION OF BENEFITS FORM
Dear Patient:
In many cases insurance carriers will coordinate medical benefits with other insurance by which you may be covered. The primary carrier pays first when there is more than one insurance company or health care provider. Please take a moment to complete the following information so that we may expedite your claim process.
Patient Name: _______________________________________________ Subscriber’s Name:__________________________________
Patient ID#: _________________________________________________ Group Name and #: _________________________________
SECTION 1- COMPLETE THIS SECTION- IF SECTIONS 2 AND 3 ARE NOT APPLICABLE PROCEED TO SECTION 4.
Date of visit: ___________________________________ Referred by: _______________________________________________________
What are we seeing you for today?
________________________________________________________________________________________________________________________
Is the reason for your visit due to an injury caused by an accident? Yes No
Date of Accident/Injury:________________________ Related to: Auto Work School Other
How, when and where did the accident occur? ____________________________________________________________________
If no, please explain the problem: When did the problem start? _________________________________________________
Was a third party responsible for your injury? Yes No
If yes, please provide the following: Name and address of individual or company ________________________________________________________________________________________________________________________
Are you currently working? Yes No If no, last date that you worked? ______________________________________
Do you have an attorney? Yes No
If yes, name and phone number: ____________________________________________________________________________________
SECTION 2- COMPLETE ONLY IF YOUR SPOUSE IS THE INSURED FOR THE PRIMARY INSURANCE
Full name of your spouse _______________________________________________________ SS# _______________________________
Spouse’s employer ______________________________________________________________ DOB: _____________________________
Is your spouse covered by any health insurance company? Yes No
If yes, please provide name of insurance carrier ___________________________________________________________________
SECTION 3- COMPLETE ONLY FOR CHILDREN UNDER 18 AND/OR FULL TIME STUDENTS
Full name of father______________________________________________________________SS#_________________________________
Father’s DOB:____________________________________ Father’s employer: ______________________________________________
Is your father covered by any health insurance company? Yes No
If yes, please provide name of insurance carrier___________________________________________________________________
Full name of mother _____________________________________________________________ SS#_______________________________
Mother’s DOB: __________________________________ Mother’s employer: ______________________________________________
Is your mother covered by any health insurance company? Yes No
If yes, please provide name of insurance carrier ___________________________________________________________________
SECTION 4
Is your problem covered by any other insurance? Yes No
To the best of my knowledge the statements above are accurate and complete. Unanswered questions indicate they do not apply. My signature authorizes my insurance to receive any and all information concerning claims filed by me or on my behalf to another insurance carrier.
_____________________________________________________________ _________________________________________________________ Patient or Designated Representative Signature Printed Name Date
MEDICAL ASSIGNMENT OF BENEFITS, AUTHORIZATION FOR TREATMENT AND PAYMENT RESPONSIBILITY
THE UNDERSIGNED hereby authorizes Belongie Orthopedics, LLC (“Provider”) to render treatment to patient. Patient agrees to cooperate with all reasonable requests by Provider in connection with Provider’s rendition of services.
THE UNDERSIGNED hereby certifies that all information provided to Provider by the undersigned or patient including any information in connection with applying for payment under title XVIII of the Social Security Act is true and accurate in all respects
THE UNDERSIGNED hereby authorizes Provider to disclose any information, furnished to Provider or obtained by Provider in connection with patient’s treatment (including information concerning a related Medicare claim) to any governmental agency (including Social Security Administration or any of its intermediaries or carriers, insurance company or health care facility requesting such information.
THE UNDERSIGNED hereby assigns Provider all Medicare benefits to which patient may be entitled for any services rendered by Provider. In addition, the undersigned approves contact with appropriate family members for medical purposes.
THE UNDERSIGNED hereby assigns to Provider all private medical insurance benefits (primary and secondary, including medi gap providers) or other benefits to which patient may be entitled for any services rendered by Provider. The undersigned hereby authorizes and directs Provider to apply and file all such benefits on behalf of patient.
THE UNDERSIGNED agrees that the undersigned shall be ultimately financially responsible for any portion of Provider’s claim that is not paid. The undersigned understands that Medicare or any health maintenance organization (HMO) may deny some charges that the physician deems necessary. Medicare and other HMO’s have denied payment for some soft goods and services (i.e. braces, crutches, walkers, cast shoes, arm slings, ace wraps, cold therapy machines, casting material, etc). The undersigned agrees to be responsible for payment of these charges should they be denied for payment. Payment of your account is your responsibility regardless of your insurance coverage. If your insurance does not pay the Provider’s claim within 90 days, any balance due will become the undersigned or patient responsibility.
THE UNDERSIGNED and patient agree to execute any documents and perform any acts that Provider may reasonably request. The undersigned warrant and represent that attached hereto are originals or certified copies of any applicable powers of attorney, health care surrogate forms or court orders appointing the undersigned as the legal guardian of patient.
THE UNDERSIGNED agrees that the provisions hereof shall continue in full force and effect until provider has received written notice of termination signed by the undersigned; however the above mentioned paragraphs 2, 4, 5 and 6 shall survive any such termination.
THE UNDERSIGNED grants permission for the Provider to treat the undersigned and/or minor child and/or dependent. If minor, parent and/or guardian must be present at time of first visit. If minor is returning for the same injury or problem, parent and/or guardian does not have to be present, however a signed consent to treat letter will need to accompany the minor. If patient is involved in high school athletics the undersigned gives authorization to provide details to high school coach, athletic director or others involved with sports activities.
THE UNDERSIGNED agrees that treatment by the Provider will not be construed as willingness on the part of the Provider to be a witness in a personal injury litigation case.
THE UNDERSIGNED understands that confabulation or fabrication either by commission or omission will be sufficient reason for unilateral discontinuation of treatment and cancellation of any contract either expressed or implied.
THE UNDERSIGNED agrees that xrays and laboratory tests are the property of the Provider and the fees charged for these services are the processing and interpretation. These records or their copies will be released at the discretion of the Provider. A nominal fee may be charged to cover additional expense for their release.
___________________________________________ _________________________________ ______________
Patient or Designated Representative Signature Printed Name Date
Acknowledgement of Receipt of Notice
I acknowledge that I have had the opportunity to review a copy of Belongie Orthopedics, LLC’ Notice of Privacy Practices (“Notice”). I understand that I am responsible to read this Notice and notify Belongie Orthopedics, LLC, in writing, of any request for restrictions in the use or disclosure of my PHI. I understand Belongie Orthopedics, LLC has the right to revise this notice at any time and will post a copy of the current Notice in the office in a visible location at all times and on their website at . Belongie Orthopedics, LLC will provide me with a copy of its most recent Notice upon my request.
*Please sign and return a copy of this Notice to Belongie Orthopedics, LLC
Patient Name: ______________________________________________ Date: _____________________
*I acknowledge that I have read and understand Belongie Orthopedics, LLC’ Financial Responsibility Policy and Prescription Drug Policy
Patient Name: ______________________________________________ Date: ______________________
*Please name the individuals with whom you authorize Belongie Orthopedics, LLC to communicate Personal Health Information (PHI) to:
Name: _________________________________ Phone: ______________________ Relation: ______________
Name: _________________________________ Phone: ______________________ Relation: ______________
Name: _________________________________ Phone: ______________________ Relation: ______________
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