South Shore Orthopedic Associates, P

South Shore Orthopedic Associates, P.C.

PLEASE PRINT PATIENT REGISTRATION

Patient’s Name ______DOB______/______/______M F

Social Security Number ______

Street Address______Apt/Suite______

City______State______Zip______

Home Phone ______-______-______Work Phone______-______-_____ Ext______

Insurance Subscriber’s Name______

Patient’s Relationship to Subscriber: Self___ Spouse___Dependent Child___ Other____

How Were You Referred? ______

GUARANTOR (Insurance Subscriber) INFORMATION

Guarantor’s Street Address______Apt. Suite______

City______State______Zip______

Home Phone ______-______-______Work Phone ______-______-______Ext______

Subscriber’s Employer______

Employer’s Address______

City ______State______Zip______EMERGENCY CONTACT

Name______

Relationship to Patient______

Address______Apt/Suite______

City______State______Zip ______

Home Phone______-______-______Work Phone ______-______-______Ext______

Please Complete if applicable

WORKERS COMPENSATION

Carrier______

Contact ______

Carrier’s Address______

City ______State______Zip______

Injury Date ______-______-______Employer Group:______Claim # ______

Comments______

ATTORNEY

Firm ______Attorney______Address______

City ______State ______Zip ______

Comments ______

MOTOR VEHICLE ACCIDENT

Auto Insurance Carrier______

Address______

City ______State ______Zip______

Date of Accident______/______/______Policy #______

Policy Holder______Carrier’s Phone # ______-______- ______

Physician/Pharmacy Info (IMPORTANT PLEASE COMPLETE)

Primary Care Physician______Phone #______

Address______State ______Zip______

Pharmacy Name______Town______Phone #______

INSURANCE INFORMATION

Primary Insurance______

Address ______

City ______State ______Zip______Phone #______

Policy #______Group # ______Name of Policy Holder: ______

Secondary Insurance ______

Address ______

City ______State ______Zip______Phone #______

Policy #______Group # ______

Name of Policy Holder: ______

***PATIENT CONSENT***

I verify that the above information is accurate and agree to inform South Shore Orthopedic Associates of any changes that may occur as soon as I am aware of the changes.

AUTHORIZE FOR RELEASE OF INFORMATION TO PAYORS AND/OR CAREGIVERS: I authorize South Shore Orthopedic Associates and any physician giving care to me or my dependent child, to release medical or other information necessary for the (1) completion of insurance claims or receipt of benefits, (2) review of the quality and appropriateness of my care by representatives of external agencies designated by law to conduct such reviews. I understand that South Shore Orthopedic Associates will forward copies of all or part of my medical record to any physician participating in my care and to any facility to which I may be admitted or transferred. If my care is related to an accident at work, I understand my employer’s Worker’s Compensation Carrier will also have access to information contained in my medical record.

ASSIGNMENT OF BENEFITS: I authorize and request payment of medical benefits to be made directly to this office for services rendered. I UNDERSTAND THAT MY INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL SERVICES rendered on my behalf or my dependents. I understand that my insurance carrier may require me to obtain a referral PRIOR to my visits. I also understand that if I FAIL TO OBTAIN RFEERRALS PRIOR TO MY VISITS, I WILL BE RESPONSIBLE FOR PAYMENT.

MEDICARE AUTHORIZATION: (Medicare Recipients Only) I certify the information given to me in applying for payment of Medicare benefits under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and the Health Care Financing Administration or its intermediaries or carriers any information needed for this or related Medicare claim. I request that the payment of authorized benefits to be made on my behalf to South Shore Orthopedic Associates or any physician providing service during my treatment.

ACKNOWLEDGE OF RECEIPT-AN IMPORTANT MESSAGE FROM MEDICARE: If I am Medicare eligible, my signature only acknowledges my receipt of this message from South Shore Orthopedic Associates and does not waive any of my rights to request a review or make me liable for any payment.

SIGNATURE: I have read the information above or have had it read to me. I understand the information and my questions have been answered to my satisfaction. My signature below verifies that I voluntarily consent to the above.

Signature of Patient (Authorized Representative) Relationship Date

Witness: ______ORTHOPEDIC HISTORY (Please Complete Both Sides)

Name: ______Today’s Date: ______/______/______

SS#: ______Date of Birth: ______/______/______

Why are you seeing the doctor today? ______

Current problem is a result of a(n): Check all that apply

 Motor Vehicle Accident  Work Accident  Accidental Injury  Other

MEDICATIONS

MEDICATION DOSE REASON FOR MEDICATION SIDE EFFECTS

ALLERGIES: (Medications, Anesthesia, and/or Adhesive tape) Please list with type of reaction

REVIEW OF SYSTEMS

Are you currently having or have you had problems with:

CIRCLE Describe if Yes

Arthritis No Yes ______Balance Problems No Yes ______Blackouts/ Fainting No Yes ______Bleeding Problems No Yes ______Cancer No Yes ______Chronic Infections No Yes ______Coronary Disease No Yes ______Diabetes No Yes ______Digestive Disorders No Yes ______Epilepsy No Yes ______Gout No Yes ______Hepatitis No Yes ______High Blood Pressure No Yes ______Immune Deficiency No Yes ______Kidney/Bladder No Yes ______Lungs, Breathing No Yes ______Phlebitis No Yes ______Scoliosis No Yes ______TB No Yes ______

PAST MEDICAL HISTORY

Surgeries/Hospitalization Year Complications

Have you ever had general anesthesia? No Yes Have you had problems with anesthesia? No Yes Describe ______

FAMILY HISTORY Alive Deceased AGE HEALTH CONDITION/CAUSE OF DEATH

Grandmother (mom’s) A D______

Grandfather (mom’s) A D______

Grandmother (dad’s) A D______

Grandfather (dad’s) A D______

Father______A D______

Mother______A__ D______

Sister/Brother______A__ D______

Sister/Brother______A_ D______

Sister/Brother______A____ D______

SOCIAL HISTORY

Age: ______Height: ______Weight:______

Occupation: ______

Are you ____Right Handed ____ Left Handed

Do you live alone? (Circle) No Yes

Do you exercise?(Circle) No Yes Describe Exercise/Activity ______

Smoke Currently? (Circle) No Yes #______Packs per day for ______years.

Drink Alcohol? ____ Daily ____ 1-2x/week ____ 1-2x/month ____ 1-2x/year

Other habits, please describe ______

Patient’s Signature ______Date ______/______/______

Reviewed By ______Date ______/______/______