Orthopedic Medical Center2
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Orthopedic Medical Center2 Account # Patient Name Address Home Phone Work Phone SS Number Cell Phone Marital Status E-Mail LL Date of Birth Sex: Employer EMERGENCY CONTACT Phone: Name: GUARANTOR INFORMATION ( IF PATIENT IS A MINOR) SAME AS PATIENT Name Address SS Number Date of Birth HISTORY WHAT TYPE OF INJURY INCURRED? Work Comp. Auto Accident Personal Injury Other EXPLAIN WHAT PORTION OF YOUR BODY WAS INJURED OR REQUIRES TREATMENT? WHICH SIDE? HOW DID THE INJURY OCCUR OR WHAT WAS THE ONSET OF CONDITION? DATE WHERE DID IT OCCUR? DID YOU RECEIVE PRIOR MEDICAL CARE? WHERE? IF IN HOSPITAL, NAME OF HOSPITAL FROM: I AM: Left Handed TO: Right Handed WHO REFERRED YOU TO THIS OFFICE? NAME PHONE Dr. Hospital Relative Friend DO YOU HAVE AN ATTORNEY REPRESENTING YOU? YES NO Name: Address Phone: PRIMARY CARE PHYSICIAN NAME: Phone Number: Address Fax Number: INSURANCE INFORMATION (PRIMARY) Insurance Company Address Phone Contact Policy/Claim/ID # Group # INSURANCE INFORMATION (SECONDARY) Insurance Company Address Phone Contact Policy/Claim/ID Group # Patient’s Signature Date RESEDA WESTLAKE VILLAGE 18039 Sherman Way, Reseda, CA 91335-4630 1240 S. Westlake Blvd., Suite 237, Westlake Village, CA 91361-1936 Tel 818.708.8100 Fax 818.705-8818 Tel 805.373.3700 Fax 805.371.3717 Orthopedic Medical Center2 Patient Name: DOB: e-mail address: We ask because we care. Why are we asking patients about their preferred language, ethnicity, and race? Healthcare organizations will use this information t o learn more about the health needs of our community and better design our services to meet those needs. It will also help us to continue to improve the quality of healthcare we provide to all our patients. Orthopedic Medical Center uses an electronic medical record system that allows electronic prescribing of medications. Medications are sent to your pharmacy through a secure electronic prescription connection (Surescripts) which improves the timely and accurate transmission of your medication information. To optimize the use of this electronic capability, and coordinate your care between us and your specialists, we ask that patients allow us to access their medication history. I consent to allow my provider to access all of my medication history. ____________________ ( Patient’s Initials) PHARMACY INFORMATION NAME ADDRESS STREET CITY STATE ZIP PHONE NUMBER FAX NUMBER Patient Signature: Date: OFFICE USE ONLY : Entered in the System: Initials Language Abkhazian French Macedonian Somali Afar Fulah Malagasy Sotho, Southern Afrikaans Ganda Malay Spanish Akan Georgian Malayalam Sundanese Albanian Georgian Maldivian Swahili Amharic Maltese Swati German Gikuyu Manx Swedish Arabic Aragonese Greek, Modern (1453-) Maori Tagalog Greek, Modern (1453-) Maori Tahitian Armenian Armenian Greenlandic Marathi Tajik Assamese Guarani Marshallese Tamil Avaric Gujarati Mongolian Tatar Avestan Haitian Nauru Telugu Aymara Hausa Ndebele, North Thai Azerbaijani Hebrew Ndonga Tibetan Bambara Herero Nepali Tigrinya Bashkir Hindi Northern Sami Tonga (Tonga Islands) Basque Hiri Motu Norwegian Tsonga Basque Norwegian Bokmal Tswana Hungarian Belarusian Icelandic Norwegian Nynorsk Turkish Bengali Ido Nuosu Turkmen Bihari languages Igbo Occidental Twi Bislama Indonesian Occitan (post 1500) Uighur Bosnian Interlingua Ojibwa Ukrainian Breton Inuktitut Old Slavonic Urdu Bulgarian Inupiaq Oriya Uzbek Burmese Irish Oromo Valencian Central Khmer Ossetian Venda Italian Chamorro Pali Japanese Vietnamese Chechen Javanese Volapük Persian Chichewa Kannada Polish Walloon Kanuri Portuguese Welsh Chinese Chuvash Kashmiri Punjabi Western Frisian Cornish Kazakh Pushto Wolof Corsican Kinyarwanda Quechua Xhosa Cree Komi Romanian Yiddish Croatian Kongo Romansh Yoruba Rundi Zhuang Czech Korean Danish Kuanyama Russian Declined to specify Kurdish Samoan Declined to specify Dutch Kyrgyz Sango Dzongkha Lao Sanskrit Latin Sardinian English Esperanto Latvian Scottish Gaelic Estonian Limburgish Serbian Ewe Lingala Shona Faroese Lithuanian Sindhi Fijian Luba-Katanga Sinhalese Luxembourgish Slovak Finnish Macedonian Slovenian French Race American Indian or Alaska Native Egyptian Laotian Polish English Law Prohibited Polynesian African African American Ethiopian Lebanese Saipanese Arab European Liberian Samoan Armenian Fijian Madagascar Scottish Malaysian Singaporean Asian Filipino Asian Indian French Maldivian Solomon Islander Assyrian German Mariana Islander Sri Lankan Bahamian Guamanian Marshallese Syrian Bangladeshi Guamanian or Chamorro Melanesian Tahitian Barbadian Haitian Micronesian Taiwanese Bhutanese Hmong Namibian Thai Black Indonesian Native Hawaiian or Other Tobagoan Pacific Islander Black or African American Iranian Nepalese Tokelauan Botswanan Iraqi New Hebrides Tongan Burmese Irish Nigerian Trinidadian Cambodian Israeili Okinawan Unknown Carolinian Italian Other Pacific Islander Vietnamese Chamorro Iwo Jiman West Indian Other Race Jamaican Pakistani Chinese White Chuukese Japanese Palauan Yapese Kiribati Palestinian Zairean Declined to specify Dominica Islander Papua New Guinean Korean Other Race Dominican Kosraean Pohnpeian Declined to specify Ethnic Group Andalusian Chilean La Raza Puerto Rican Argentinean Colombian Latin American Salvadoran Asturian Costa Rican Law Prohibited South American Belearic Islander Criollo Mexican South American Indian Bolivian Cuban Mexican American Spaniard Canal Zone Mexican American Indian Spanish Basque Declined to specify Canarian Dominican Mexicano Uruguayan Castillian Ecuadorian Nicaraguan Valencian Catalonian Gallego Not Hispanic or Latino Venezuelan Central American Guatemalan Panamanian Not Hispanic or Latino Central American Indian Hispanic or Latino Paraguayan Declined to specify Chicano Honduran Peruvian Unknown Orthopedic Medical Center2 FINANCIAL AGREEMENT PRIVATE INSURANCE POLICY I authorize the above doctor and/or medical facility to bill my insurance company as a courtesy. I agree to give said doctor information regarding any and all insurance policies which may cover said medical treatment and assign to him the benefits therein. I further agree to notify said doctor, and pay his billings at such time as I may personally receive payments made directly to myself for these services from my own or any other medical insurance carrier. I do fully realize and understand that I remain personally responsible for said medical services and associated medical billings. If, for any reason, a dispute should arise with my insurance company regarding these claims, I agree that it is my responsibility to rectify the situation; and that if my insurance company needs time to review claims, said office is not obligated to wait for any payment to be issued. Instead, they may, after a reasonable waiting period, request payment from me, and I can receive reimbursement from the insurance company. Knowing your insurance benefits – including eligibility, covered benefits, and medically necessary procedures is your responsibility; please contact customer services at your insurance company for questions regarding In-Network Status and coverage. You are responsible for any charges not covered by your plan. I further understand that I will be receiving statements of my account. Such statements will reflect an itemization of charges as well as payments and outstanding balances. I understand that I am personally responsible for the unpaid balance, and I agree to pay said facility such sums in full unless otherwise agreed. Should the account be referred to an attorney for collection; I agree to pay reasonable attorney’s fees and collection expense. I certify that I am the patient or an agent duly authorized to execute this agreement, that I have read this agreement, and have received a true and complete copy of it. MEDICARE PRIMARY INSURANCE ONLY We are happy to bill your Insurance for you and we do accept assignment. Accepting assignment means that we will accept as payment in full what Medicare and/or Medi-Cal allows for fees charged. You, however will be responsible for paying any deductibles, co- insurances, and non-covered expenses. Non-covered expenses would include prescribed medications dispensed by this office, dressings, bandages, cast guards, crutches, etc. We will also bill any secondary insurance for you, such as AARP, but they will also not pay for any expenses not allowed by Medicare and/or Medi-Cal. Please be sure that you have a complete understanding of what expenses you will be responsible for before signing below. H.M.O. POLICY The physicians and Staff are happy to see H.M.O. patients which have been referred to this office for examinations and treatment. As an H.M.O. patient, it is important to remember that ALL SERVICES must be approved by your primary physician and/or the appropriate utilization review personnel. Our contracts with each H.M.O. & I.P.A. vary most notably in regard to such services as x-ray, and dispensing of durable goods. If your H.M.O. covers durable goods we are happy to request authorization for them. You will then be referred to a contracted facility that your H.M.O. specifies. This office will not adjust durable goods dispensed by any other facility. If diagnostic testing such as M.R.I., Ultrasound, C.T. Scan, Lab tests and in some cases an x-ray needed, we will request to the proper source to help obtain authorization. · If you would like this facility to dispense any durable goods that are not covered, or that you are willing to pay for on your own, we will be happy to price that item for you and dispense it at your own