Miguel Pupiales, MD PC

Miguel Pupiales, MD Pain Free New Mexico 630 Manzano Street NE, Suite D Albuquerque, NM 87110 Phone 505.344.7246 Fax 505.344.2666

NEW PATIENT INTAKE FORM

Please complete the following questionnaire. Once completed, please return to the front desk and present your insurance card to the receptionist. Thank you.

PATIENT INFORMATION

NAME______DOB____/____/____SS#____/___/_____ (LAST) (FIRST) (MIDDLE)

HOME ADDRESS:______HOME #_____-______-_____ CELL # ____-_____-_____ WORK#____-____-______

PLEASE CIRCLE: MALE/FEMALE

MARITAL STATUS: SINGLE/MARRIED/DIVORCED/WIDOWED

PERSON TO CONTACT IN EMERGENCY:______(NAME) (RELATIONSHIP) (PHONE) REFERRED BY:______PRIMARY CARE PHYSICIAN______REFERRING MD:______

RACE: WHITE/AFRICAN AMERICAN/NATIVEAMERICAN INDIAN/ASIAN OTHER:______

CURRENT EMPLOYMENT INFORMATION

EMPLOYED: F/T P/T RETIRED UNEMPLOYED F/T STUDENT P/T STUDENT EMPLOYER:______WORK #____-____-______ADDRESS:______SUPERVISOR:______POSITION:______

IS THIS INJURY WORK RELATED: _____AUTO ACCIDENT:_____DATE OF INJURY:______

D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc WORKERS’ COMPENSTATION INSURANCE INFORMATION

WORK COMP INSURANCE COMPANY______(NAME) ______(ADDRESS, CITY, STATE, ZIP CODE)

ADJUSTERS NAME:______PHONE:______MEDICAL CASE MANAGER:______PHONE:______ATTORNEY:______PHONE:______

DATE OF INJURY:____/_____/______EMPLOYER AT TIME OF INJURY______

CLAIM #______

PRIMARY INSURANCE INFORMATION

PRIMARY INSURANCE COMPANY:______(NAME, ADDRESS, CITY, STATE, ZIP CODE) GROUP#______ID#______PHONE#______

INSURED’S NAME:______DATE OF BIRTH:______RELATIONSHIP TO PATIENT:______ADDRESS OF INSURED:______

SECONDARY INSURANCE INFORMATION

SECONDARY INSURANCE COMPANY:______(NAME, ADDRESS, CITY, STATE, ZIP) GROUP#______ID#______PHONE#______

INSURED’S NAME:______DATE OF BIRTH:______

RELATIONSHIP TO PATIENT:______

AUTHORIZATION TO PAY PHYSICIAN

I HEREBY AUTHORIZE PAYMENT OF MEDICAL BENEFITS DIRECTLY TO MIGUEL PUPIALES, MD PC FOR TREATMENT OF THIS INJURY/ILLNESS.

AUTHORIZATION TO TREAT AND RELEASE INFORMATION

D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc I HEREBY AUTHORIZE MIGUEL PUPIALES, MD PC TO EXAMINE AND TREAT AS NECESSARY. THE PHYSICIAN MAY RELEASE INFORMATION ACQUIRED IN THE COURSE OF THIS EXAMINATION OR TREATMENT TO MY EMPLOYER, INSURANCE CARRIER, OR ANY OTHER PHYSICIAN, IF REQUESTED BY ME OR MY EMPLOYER. THE UNDERSIGNED ALSO AUTHORIZES MIGUEL PUPIALES, MD PC TO RELEASE TO THE PROSPECTIVE EMPLOYER, INSURANCE CARRIER, OR ANY OTHER PHYSICIAN WHETHER BY PHONE, FAX, OR MAIL. ANY AND ALL INFORMATION HELD BY MIGUEL PUPIALES, MD OC MAY HAVE BEEN OBTAINED FROM ANY PRIOR EXAMINATION PROCEDURE OR TREATMENT RENDERED TO THE UNDERSIGNED BY MIGUEL PUPIALES, MD PC.

PATIENT SIGNATURE:______DATE:______

PATIENT IS RESPONSIBLE FOR PAYMENT OF DENIED CLAIMS

PATIENT CONDITION QUESTIONAIRE

1. Was there a specific injury that caused your pain? What happened and when? ______

2. Where is the pain located? ______

3. How often does it occur? All the time, times/day, week ______

4. How long does it last? ______

5. Is there anything that brings it on or makes it worse? ______

Sitting, standing, kitchen counter, bending, lifting, getting in or out of car, driving

D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc Does it wake you up at night? ______

6. Anything make it feel better? ______

Sitting, lying down, bending, arching back, heat, cold

7. Medications that help? ______

8. Feels like? Ache/burning/stabbing/sharp

9. Other symptoms? Tingling/numbness/pins and needles

10. Does the pain go down your legs/(or arms)? Y/N

Right? Left? Both? How far down? Back or front? Inside or outside? To the foot/ (hand)? Big toe side or little toe side/(Pinkie or thumb)? ______

11. Numbness or tingling same as above location questions? ______

12. How long does it last? ______

13. Do you have a home exercise program? How often?

14. Are you on a weight loss program?

15. Any MRI’s performed? Yes / No If YES: When? ______

16. Any x-rays performed? Yes / No If YES: When? ______Where were they performed? Address ______What body part was scanned? ______

17. Any CAT scans performed? Yes / No If YES: When? ______Where were they performed? Address ______What body part was scanned? ______

18. Any surgeries performed? If YES: List procedure and date: ______

19. Any injections performed? If YES: List procedure and date: ______

D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc 20. Who is your Primary Care Provider? ______Phone/Fax Numbers ______

21. All medications you are taking, please list.

22. Please list any drug allergies:

______

23. What is your Pharmacy of Choice? (Please only use one pharmacy for medication)

Name of Pharmacy______Location______Phone______

24. What is your preferred language? ______

*WHAT TREATMENT HAS THERE BEEN? PLEASE MARK WITH AN “X” THE TREATMENTS YOU HAVE TRIED IN THE PAST:

____ ANTI-INFLAMMATORY MEDICATION ____ MUSCLE RELAXANT MEDICATION ____ ANTI-DEPRESSANT MEDICATION ___ NARCOTIC PAIN MEDICATION ____EXERCISE ___ COLD/HEAT ____ ULTRASOUND ____ TENS UNIT ___ BACK BRACE ____TRACTION ____ MASSAGE ____ CHIROPRACTIC _____COUNSELING ____ WORK HARDENING _____ EPIDURAL INJECTION _____ ACUPUNCTURE _____ SURGERY _____ PAIN MANAGEMENT PROGRAM

D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc ____ TRIGGER POINT INJECTIONS ____ PHYSICAL THERAPY

REVIEW OF SYSTEMS

Circle if self. Check if relative.

GENERAL NEUROLOGICAL

Chills Y/N Dizziness Y/N

Night Sweats Y/N Double Vision Y/N

Weight Loss Y/N Blurred Vision Y/N

Weight Gain Y/N Numb or Tingling Sensations Y/N Fevers Y/N Weakness Y/N

Visual Disturbance Y/N CARDIOVASCULAR

Chest Pain Y/N

Chest Pain with Exercise Y/N

Swelling of the legs Y/N

Palpitations Y/N PULMONARY

Pedal Edema Y/N Cough Y/N

Murmur Y/N Shortness of breath at Rest Y/N Other Valvular Problems Y/N Shortness of breath With exercise Y/N

D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc Wheezing Y/N

GASTROINTESTINAL

Diarrhea Y/N GU

Heart Burn Y/N Painful Urination Y/N

Acid Reflux Y/N Urgency Y/N

Abdominal Pain Y/N Hesitancy Y/N

Vomiting Y/N Discharge Y/N

Nausea Y/N Incontinence Y/N

MUSCULOSKELETAL PSYCHOLOGICAL

Joint Pain Y/N Depression Y/N

Stiffness Y/N Anxiety Y/N

Muscle Spasm Y/N Insomnia Y/N

Limitation in Neck Movement Y/N Mood Swings Y/N

D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc ENDOCRINE DERMATOLOGICAL

High Thirst Y/N Rash Y/N

Urinary Frequency Y/N Itch Y/N

Weight Gain/Loss Y/N Skin Infection Y/N

Appetite Change Y/N Bruising Y/N

Rapid Heart Rate Y/N

PAST MEDICAL HISTORY

Stroke Y/N Rhythm Disturbance Y/N

Seizure Y/N High blood pressure Y/N

Asthma Y/N Ulcers Y/N

Pneumonia Y/N Diverticulitis Y/N

TB Y/N GERD Y/N

COPD Y/N Kidney Infections Y/N

Heart Attack Y/N Kidney Stones Y/N

Diabetes Y/N Thyroid Disease Y/N

Anemia Y/N Rheumatoid Arthritis Y/N

D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc PLEASE SHOW THE LOCATION OF YOUR PAIN BY DRAWING ON THE FIGURES BELOW:

*PLEASE LIST ALL CURRENT MEDICATIONS

PLEASE LIST ALLERGIES:______

HOW SEVERE IS YOUR PAIN ON AVERAGE? (O=NO PAIN, 10=WORST PAIN IMAGINABLE) 0-1-2-3-4-5-6-7-8-9-10

FAMILY HISTORY: SURGICAL HISTORY(What surgeries and when) HEART DISEASE: ______CANCER: ______DIABETES: ______

SOCIAL HISTORY: DO YOU SMOKE? (IF YES HOW MANY PACKS PER DAY) DO YOU DRINK ALCOHOL? DO YOU HAVE A HISTORY OF DRUG OR ALCOHOL ABUSE? MARRIED? CHILDREN? OCCUPATION:

D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc NOTICE OF HEALTH INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. INTRODUCTION DR. MIGUEL PUPIALES IS COMMITTED TO TREATING AND USING PROTECTED HEALTH INFORMATION ABOUT YOU RESPONSIBLY. THIS NOTICE OF HEALTH INFORMATION PRACTICES DESCRIBES THE PERSONAL INFORMATION WE COLLECT, AND HOW AND WHEN WE USE OR DISCLOSE THAT INFORMATION. IT ALSO DESCRIBES YOUR RIGHTS AS THEY RELATE TO YOUR PROTECTED HEALTH INFORMATION. THIS NOTICE IS EFFECTIVE OCTOBER 16, 2002, AND APPLIES TO ALL PROTECTED HEALTH INFORMATION AS DEFINED BY FEDERAL REGULATIONS. UNDERSTANDING YOU HEALTH RECORD/INFORMATION  EACH TIME YOU VISIT THE OFFICE OF MIGUEL PUPIALES, MD A RECORD OF YOUR VISIT IS MADE. TYPICALLY, THIS RECORD CONTAINS YOUR SYMPTOMS, EXAMINATION AND TEST RESULTS, DIAGNOSES, TREATMENT, AND A PLAN FOR FUTURE CARE OF TREATMENT. THIS INFORMATION OFTEN REFERRED TO AS YOUR HEALTH OR MEDICAL RECORDS SERVE AS A: o BASIS FOR PLANNING YOUR CARE AND TREATMENT. o MEANS OF COMMUNICATION AMONG THE MANY HEALTH PROFESSIONALS WHO CONTRIBUTE TO YOUR CARE o LEGAL DOCUMENTS DESCRIBING THE CARE YOUR RECEIVED, o MEANS BY WHICH YOU OR A THIRD-PARTY PAYER CAN VERIFY THAT SERVICES BILLED WERE ACTUALLY PROVIDED, o A TOOL WITH WHICH WE CAN ASSESS AND CONTINUALLY WORK TO IMROVE THE CARE WE RENDER AND THE OUTOMES WE ACHIEVE, o UNDERSTANDING WHAT IS IN YOUR RECORD AND HOW YOUR HEALTH INFORMATION IS USED HELPS YOU TO: . ENSURE ITS ACCURACY, BETTER UNDERSTAND WHO, WHAT, WHEN, WHERE, AND WHY OTHERS MAY ACCESS YOU HEALTH INFORMATION, AND MAKE MORE INFORMED DECISIONS WHEN AUTHORIZING DISCLOSURE TO OTHERS YOUR HEALTH INFORMATION RIGHTS ALTHOUGH YOUR HEALTHRECORD IS THE PHYSICAL PROPERTY OF THE OFFICE OF MIGUEL PUPIALES, MD THE INFORMATION BELONGS TO YOU. YOU HAVE THE RIGHT TO:  OBTAIN A PAPER COPY OF THIS NOTICE OF INFORMATION PRACTICE UPON REQUEST  INSPECY AND COPY YOUR HEALTH RECORD AS PROVIDED FOR IN 45 CFR 164.524  OBTAIN AN ACCOUNTING OF DISCLOSURE OF YOUR HEALTH INFORMATION AS PROVEDED IN 45 CFR 164.528  REQUEST A RESTRICTION ON CERTAIN USES AND DISCLOSURES OF YOUR INFORMATION AS PROVIDED BY 45 CFR 164.522 AND  REVOKE YOU AUTHORIZATION TO USE OR DISCLOSE HEATLH INFORMATION EXCEPT TO THE EXTENT THAT ACTION HAS ALREADY BEEN TAKEN. OUR RESPONSIBILITES ARE TO:  MAINTAIN THE PRIVACY OF YOUR HEALTH INFORMATION  PROVIDE YOU WITH THIS NOTICE AS TO OUR ‘LEGAL’ DUTIES AND PRIVACY PRACTICES WITH RESPECT TO INFORMATION WE COLLECT AND MAINTAIN ABOUT YOU,  ABIDE BY THE TERMS OF THIS NOTICE,  NOTIFY YOU IF WE ARE UNABLE TO AGREE TO A REQUESTED RESTRICTION, AND  ACCOMMODATE REASONABLE REQUESTS YOU MAY HAVE TO COMMUNICATE HEALTH INFORMATION BY ALTERNATIVE MEANS OR AT ALTERNATIVE LOCATIONS.

WE RESERVE THE RIGHT TO CHANGE OUR PRACTICE AND TO MAKE THE NEW PROVISIONS EFFECTIVE FOR ALL PROTECTIVE HEALTH INFORMATION WE MAINTAIN. SHOULD OUR INFORMATION PRACTICE CHANGE, WE WILL MAIL A REVIEWED NOTICE TO THE ADDRESS YOU’VE SUPPLIED US. WE WILL NOT USE OR DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION, EXCEPT AS DESCRIBED IN THIS NOTICE. WE WILL ALSO DISCONTINUE USING OR DISCLOSING YOUR HEALTH INFORMATION AFTER WE HAVE RECEIVED A WRITTEN REVOCATION OF THE AUTHORIZATION ACCORDING TO THE PROCEDURES INCLUDED IN THE AUTHORIZATION.

FOR MORE INFORMATION OR TO REPORT A PROBLEM IF YOU HAVE QUESTIONS AND WOULD LIKE ADDITIONAL INFORMATION YOU MAY CONTACT THE PRACTICES’S PRIVACY OFFICER AT 505-344-7246 ext. 110. IF YOU BELIEVE YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED, YOU CAN FILE A COMPLAINT WITH THE PRACTICE’S PRIVACY OFFICER OR WITH THE OFFICE OF CIVIL RIGHTS, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; THERE WILL BE NO RETALIATION FOR FILING A COMPLAINT WITH EITHER THE PRIVACY OFFICER OR THE OFFICE FOR CIVIL RIGHTS. THE ADDRESS FOR THE OCR IS LISTED BELOW.

OFFICE FOR CIVIL RIGHTS U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 200 INDEPENDENCE AVENUE, S.W.

D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc ROOM 509F HHH BUILDING WASHINGTON, D.C. 20201

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

THE OFFICE OF DR. MIGUEL PUPIALES HAS PROVIDED ME WITH THE NOTICE OF PRIVACY POLICIES, DETAILING HOW MY INFORMATION MAY BE USED AND DISCLOSED AS PERMITTED UNDER FEDERAL AND STATE LAW. I UNDERSTAND THE CONTENTS OF THE NOTICE AND I REQUES THE FOLLOWING RESTRICTION(S) CONCERNING THE USE OF MY PERSONAL MEDICAL INFORMATION: (IF THIS DOES NOT APPLY TO YOU, PLEASE WRITE N/A)

______

FURTHER, I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED AS FORMAL ASSIGNMENT BENEFITS AND REQUEST PAYMENT OF MEDICAL INSURANCE BENEFITS TO BE PAID TO DR. MIGUEL PUPIALES FOR MY MEDICAL TREATMENT. REGULATIONS PERTAINING TO MEDICAL ASSIGNMENT OF BENEFITS APPLY.

SIGNED:______DATE:______

IF NOT SIGNED BY PATIENT PLEASE INDICATE RELATIONSHIP TO PATIENT

RELATIONSHIP:______WITNESSED BY:______

ACKNOWLEDGEMENT OF 24 HOUR CANCELLATION POLICY

I UNDERSTAND THAT THE OFFICE OF DR. MIGUEL PUPIALES WILL APPLY A $25.00 CHARGE TO MY ACCOUNT IF I FAIL TO GIVE 24 HOUR CANCELLATION NOTIVE OR IF I FAIL TO SHOW UP FOR AN APPOINTMENT.

SIGNED:______DATE:______

INTERNAL USE ONLY:

IF PATIENT OR PATIENT’S REPRESENTATIVE REFUSES TO SIGN ACKNOWLEDGEMENT OF RECEPT OF NOTICE, PLEASE DOCUMENT THE DATE AND TIME THE NOTICE WAS PRESENTED AND SIGN BELOW.

PRESENTED ON (DATE AND TIME):______

BY (NAME AND TITLE):______

D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc D:\Docs\2017-12-29\0d230b7a22a74d6e25441d4887b1e715.doc