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 Declined to specify Mexican American Indian Spanish Basque 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 request. Please remember however, that payment for durable goods is expected at the time of dispensing.
If Physical Therapy is prescribed we will request authorization for you and you will be sent to a contracted facility that your H.M.O.specifies. It is very important that you receive your therapy in a timely fashion, if you have any concerns please contact your H.M.O. customer service immediately
Please remember that if you do not have authorization prior to receiving any treatment, or if you are not eligible and your insurance company does not cover that treatment, you will be held financially responsible.
CASH PATIENTS (NO INSURANCE)
This is to confirm your agreement to pay the charges you accrue at Orthopedic Medical Center. Beginning with today's charges which would be paid in full at time of services and all future visits to be paid in the same manner.
The approximate charges for today are estimated amount only. The actual fee would depend on the severity of your condition for which you are being examined.
24 HOUR CANCELLATION & “NO SHOW” FEE POLICY
Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, Orthopedic Medical Center reserves the right to charge a fee of $30.00 for all missed appointments (“No Shows”) and appointments which are not cancelled with a 24-hour advance notice.
“No Show” fees will be billed to the patient. This fee is not covered by insurance, and must be paid prior to your next appointment. Multiple “no shows” in any 12 month period may result in termination from our practice.
Patient Name:
Dated: Patient’s Signature
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
I , have received a copy of Orthopedic Medical Center's Notice of Privacy Practices.
RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM
Patient 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
NEW PATIENT INTAKE FORM
Name(Print):______DOB: ______Today’s Date:______
Date of injury/When did the pain start?______What were you doing when the pain started? Mark an “X” in the box Lying down Sitting Standing Walking Lifting Carrying Running Pushing/pulling Riding/ Driving/ Slip/falling Trip/falling Going down stairs Climbing up stairs Turning Reaching Grasping/gripping Holding object Other (what happened?):
Put an “X” on the drawing where it hurts: Do you have:(please circle)
Weakness: Numbness Tingling
Fatigue Cramping Achiness
Burning Stabbing Spasm/cramps
Swelling Redness Other:
Is your pain GREATER on the RIGHT / LEFT or BOTH EQUAL
How bad is your pain: a little 1 2 3 4 5 6 7 8 9 10 the most ever
If you received medical attention previously for the same problem, please provide us with the doctor’s name(s):______What services were you provided?Mark an ‘X” in the box X-rays CT/MRI Sutures/ Cast/Brace Cane Crutches Hospital(How long?) Medication Tests/EMG/ECG/EEG Surgery/(When?) Other: What medications are you taking? How much medication are you taking?/Dose
Are you allergic to any medications? Yes No What?______
Do you use tobacco/smoke? Yes No How much? ______How many years ?______
PAST MEDICAL HISTORY: Have you ever had or do you currently have any medical health problems? Put an “X” in the box No health problems Kidney disorder Thyroid condition Arthritis Sinus infection Carpal tunnel Asthma Cancer Chronic fatigue Allergies Stroke Foot problems Heart condition Hernia Digestive disorder High blood pressure Epilepsy/seizure Diabetes Dental Low back Circulation Addiction Depression HIV/AIDS: Pacemaker Joint Replacement Other Females: Could you be pregnant as of today? Yes No
Patient signature:______Date: ______Provider Signature: ______Date: ______ORTHOPAEDIC REVIEW OF SYSTEMS
Today’s Date First Name ______Last Name Date of Birth ______
REVIEW OF SYSTEMS: Please check any new symptoms you have experienced:
Constitutional/General Cardiovascular Genitourinary Yes No Fever Yes No Chest Pain or Discomfort Yes No Painful urination Yes No Chills Yes No Swelling Feet, Ankles, Legs Yes No Urinary Frequency Yes No Heavy Sweating/Night Sweats Yes No Irregular Heartbeat Yes No Loss of Urinary Control Yes No Loss of Appetite Yes No Heart Attack Yes No Enlarged Prostate Yes No Sleep Disturbances Yes No Palpitations Yes No Difficulty Urinating Yes No Unexplained Weight Yes No Varicose Veins Other: ______Loss/Gain Other: ______ Other: ______Skin Gastrointestinal Yes No Skin Rash Eyes Yes No Abdominal Pain Yes No Itching Yes No Blurry Vision Yes No Nausea/Vomiting Yes No Discoloration Yes No Double Vision Yes No Indigestion/Heartburn Yes No Lumps or Masses Yes No Wear Glasses Yes No Blood in Stools Other: ______ Other: ______ Yes No Change in Bowel Habits Yes No Rectal Bleeding Musculoskeletal Ear/Nose/Throat Yes No Diarrhea Yes No Joint Pain Yes No Sore Throat Yes No Constipation Yes No Joint Swelling Yes No Mouth Sores Yes No Swallowing Difficulties Yes No Back Pain Yes No Nasal Congestion/Sinus Issues Other: ______ Yes No Limitation of Motion Yes No Hearing Loss Yes No Neck Pain Other: ______Psychological Yes No Pain with Walking Yes No Depression Other: ______Respiratory Yes No Anxiety Yes No Cough Other: ______Neurological Yes No COPD Yes No Tremors Yes No Wheezing Hematologic/Lymphatic Yes No Dizzy Spells Yes No Recurrent Respiratory Yes No Swollen Glands Yes No Numbness/Tingling Infections Yes No Blood Clotting Problem Yes No Headache Yes No Shortness of Breath Yes No Easy Bruising Yes No Unsteady Gait Other: ______ Yes No Bleeding Tendencies Yes No Feeling Weak Other: ______ Yes No Convulsions/Seizures Endocrine Other: ______ Yes No Excessive Thirst/Fluid Intake Yes No Temperature Intolerance Yes No Feeling Tired (Fatigue) Yes No Hot Flashes Other: ______
Patient Signature: Date:
Provider Signature: Date: