New Patient Packet

DEMOGRAPHICS

Patient Name:

DOB:

SSN:

Driver’s License #:

State:

Home#:

Mobile#:

Email Address:

Mailing Address:

Apt#:

City:

State:

Zip:

Employer Name:

Address:

Work Number:

Occupation:

Person to notify in case of emergency:

Relationship:

Contact #:

Primary Care Physician:

Phone#:

FINANCIAL INFORMATION

(Please be sure to fill out insurance information thoroughly)

SELF PAY INSURANCE MEDICARE WORKER'S COMP CLAIM OTHER

Primary Insurance Co.

Tel #

Insurance ID#

Group #

Insured’s Name

Insured’s Date of Birth

Relationship to Patient

Secondary Insurance Co.

Tel #

Insurance ID#

Group #

Insured’s Name

Insured’s Date of Birth

Relationship to Patient

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

Assignment Authorization/Office Fee Policy

I hereby authorize

, to release to my insurance company, any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such Medical care. I authorize and request my insurance company to pay directly to the doctor the amount due for my pending claim for medical services, by reason of such treatment or services rendered to me a photographic copy of this authorization shall be as the original. It is the policy of this office that the parent guardian accompanying the child for treatment services will be responsible for all bills. We cannot bill the other parent. We respectfully request payment of any deductible, coinsurance and/or co-payment at the time the service is rendered regardless of insurance coverage. If any insurance payments are received by our office that is due to the patient, a refund will be made to the patient.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Responsible Person:

Relationship to patient:

Date:

Medical History:

Reason for visit:

Have you ever seen another surgeon for the same problem or concern?

Yes No

Height:

Weight:

Review of Systems: (Please select yes or no.)

General:

Changes in weight

Yes No

Progressive/Prolonged Fatigue

Yes No

Pulmonary:

Cough

Yes No

Shortness of breath

Yes No

Wheeze

Yes No

Snoring

Yes No

Cardiac:

Do you ever wake up short of breath

Yes No

Leg/ Ankle swelling

Yes No

Do you sleep okay

Yes No

Palpitations / Heart flutters

Yes No

Abnormal sensation with exertion / (in chest, arms, neck, back)

Yes No

Infectious Disease:

Fever

Yes No

Night Sweats

Yes No

Recent Infection

Yes No

Gynecologic/Urologic:

Incontinence

Yes No

Difficulty / Painful urination

Yes No

Blood in urine

Yes No

Psychiatric:

Suicidal thoughts

Yes No

Hallucinations

Yes No

Memory loss

Yes No

Feeling depressed/anxious

Yes No

Blood/Lymph:

Easy bruising

Yes No

Frequent nose bleeds

Yes No

Swollen glands

Yes No

Head and Neck:

Decrease in hearing

Yes No

Ringing in the ears

Yes No

New Headaches

Yes No

Sinus Problems

Yes No

Sore throat

Yes No

Changes in voice

Yes No

Dry mouth

Yes No

Eyes:

Blurred vision

Yes No

Eye pain

Yes No

Redness

Yes No

Watering

Yes No

Light sensitive

Yes No

Dry feeling

Yes No

Gastrointestinal:

Frequent Nausea / Vomiting

Yes No

Abdominal pain

Yes No

Skin:

Changing moles

Yes No

New rash

Yes No

Tendency to form Keloid

Yes No

Neurological:

Dizziness

Yes No

Difficulty walking

Yes No

Sensory changes

Yes No

Musculoskeletal:

Weakness / Numbness

Yes No

Neck / Back Pain

Yes No

TMJ / Jaw Pain

Yes No

Do You Have Any Of The Following:

(Please Select)

High Blood Pressure

High Cholesterol

Fibromyalgia

Breathing Problems

Diabetes

Migraine Headaches

Heart Issues

Heart Issues:

Past Surgical History: (Please list name of all procedures and dates.)

Add new procedure

Medications: (Prescription and Over the Counter Medications)

Add new medication

Drug Allergies: (select one)

Yes No

List:

Social History:

Do you drink alcohol?

Yes No

How Often:

Have you ever used tobacco?

Yes No

How Long & How Much A Day?

Do you use recreational drugs?

Yes No

Family History: Please list any family medical history/problems

Father:

Age

Diseases

Cause of Death

Mother:

Age

Diseases

Cause of Death

ACKNOWLEDGEMENT:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform Loredo Hand Care Institute of any changes in my medical status. I also authorize the health care staff to perform the necessary services I may need.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date:

PATIENT HIPAA ACKNOWLEDGEMENT AND DESIGNATION DISCLOSURE FORM

I. Acknowledgement of Practice’s Notice of Privacy Practices:

By subscribing my name below, I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP), and that I have read (or had the opportunity to read if I so chose) and understand the Notice of Privacy Practices (NPP) and agree to its terms.

II. Designation of Certain Relatives, Close Friends and other Caregivers as my Personal Representative:

I agree that the practice may disclose certain of my health information to a Personal Representative of my choosing, since such person is involved with my health care or payment relating to my health care. In that case, the Physician Practice will disclose only information that is directly relevant to the person’s involvement with my health care or payment relating to my health care.

Add new row

III. Request to Receive Confidential Communications by Alternative Means:

As provided by Privacy Rule Section 164.522(b), I hereby request that the Practice make all communications to me by the alternative means that I have listed below.

Home Telephone Number:

OK to leave message with detailed information

Leave message with call back numbers only

Written Communication Address:

OK to mail to address listed above

E-mail me at:

Work Telephone Number:

OK to leave message with detailed information

Leave message with call back numbers only

Fax Communication:

OK to Fax at the number listed above

E-mail me at:

Other:

Name of Patient

Date of Birth

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Parent/Guardian

Date

INSURANCE ACKNOWLEDGMENT & ENDORSEMENTS

PATIENT LEGAL NAME

DOB

• RECORDS RELEASE

I hereby authorize Loredo Hand Care Institute to furnish any medical records and/or other necessary information needed to process an insurance claim.

• ASSIGNMENT OF BENEFITS

I, the undersigned, am the financially responsible party for the patient named above and agree to pay, in full, Loredo Hand Care Institute, for services rendered. I accept Loredo Hand Care Institute fees as reasonable and customary.

In order to process an insurance claim, there must be complete patient and insurance information on file.

I irrevocably assign Loredo Hand Care Institute, and/or its physicians all payments from insurance company(ies) for medical services rendered and accept responsibility for paying any balance owed after the insurance has paid.

Should your insurance deny payment for any and all services you are responsible for the amount billed.

All patients whose insurance providers pay the patient directly, rather than the physician, hereby agree to assign all benefit proceeds the patient receives from the insurance company to the physician’s office. I agree to immediately endorse all checks received from my insurance company and to mail or bring them into the physician’s office.

• If your insurance is an HMO you MUST have a referral from your primary care doctor (PCP) that is listed on your card. Without a referral you will be responsible for all charges.

• NON-WORKMAN’S COMP DECLARATION

PLEASE READ - THE PHYSICIAN IS UNABLE TO DETERMINE WHETHER OR NOT THE SYMPTOMS YOU ARE

SUFFERING ARE WORK RELATED.

By signing below, you declare that you do not have a compensable work injury covered under a workman’s comp claim at this time. It is your responsibility as the patient to notify our office if you file a work comp claim. You also understand that should your workman’s comp claim be denied, you will be responsible for all balances in full. If group health insurance is available, we must receive a copy for processing as soon as you are aware the claim has been denied. This is not a guarantee that we accept your group insurance.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Responsible Party

Name

Date

Hand And Elbow History:

What Do You Do For A Living?

Which Hand/Arm Hurts?

Right Left Both

How Long Has It Been Going On?

What Gives You Issues?: (Select All That Apply)

Wrist

Forearm

Hand

Thumb

Index Finger

Middle Finger

Ring Finger

Small Finger

Elbow

Do You Have Numbness And Tingling?

Yes No

How Severe Is Your Pain?:

None

Mild

Moderate

Severe

Have you had any prior treatment for your condition?

Yes No

Have you had any prior treatment for your condition?

Anti-Inflammatory/ Pain Medications

Yes No

Did This Help?/ Describe

Splints

Yes No

Did This Help?/ Describe

Cortisone Injections

Yes No

Did This Help?/ Describe

Physical Therapy

Yes No

Did This Help?/ Describe

Chiropractic

Yes No

Did This Help?/ Describe

Surgery

Yes No

Did This Help?/ Describe

Other

Have You Had An EMG/Nerve Study Done In The Past?

Referral Form

How Did You Hear About Hand Associates of North Dallas?

Doctor Referral

Name:

Address:

Specialty:

Business Referral

Type here

Patient Referral

Type here

Friend/Word Of Mouth

Type here

Television/Channel

Type here

Radio/Station

Type here

Billboard/Location

Type here

Magazine/Newspaper

Type here

Internet

Type here

Other Source

Type here

Pharmacy Information

We are currently utilizing an EMR (electronic medical records) system to schedule appointments and document patient encounters. We are now taking the next step toward electronically ordering and submitting prescriptions through the computer, otherwise known as ePrescribe. Electronic prescribing or e-prescribing is the electronic transmission of prescription information from the prescriber's computer to a pharmacy computer. It replaces a paper prescription that the patient would otherwise carry or fax to the pharmacy. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. Release of your prescription history through Rx Eligibility.

In an effort to update your medical record in our system with your preferred Pharmacy we will need to obtain this information from you. Please provide your “preferred” pharmacy as Pharmacy#1 and an alternative in Pharmcy#2. If you do not know the exact address, please list cross streets and we will try to assist you in locating the exact pharmacy. If you do not have a regular pharmacy, we can assist you by location one using a preferred zip code, such as your home or work zip code. (Please be sure to write clearly so that we can accurately enter your data into the system)

Pharmacy#1

Address (or cross streets)

City

State

Zip

Telephone #

X-Ray & Ultrasound

authorized Loredo Hand Care Institute to take x-rays and preform an ultrasound for my condition.

I understand my x-rays and ultrasound and other pertinent information related to my treatment will be presented for analysis. I further understand this information is valuable in order to assist my doctor in his evaluation of an initial treatment plan, as well as modification to this plan during the course of treatment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date:

OWNERSHIP AND REFERRAL DISCLOSURE FORM

This Disclosure Form is designed to help ensure that patients have the necessary information to make an informed decision about their medical benefits and care. A physician must notify a patient that the physician has a direct financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient, and whether these are available elsewhere on a competitive basis; patients also should be informed whether provider to which they are referred are out of network. Patients shall be given a list of effective alternative resources, if any, that are reasonably available, informed that they have the option to use one of the alternative resources, and assured that they will not be treated differently by the physician if they choose an alternative provider or entity.

Patient name

Are the services for which the patient is being referred available elsewhere on a competitive basis?

Yes No

If yes, which services are available elsewhere, and where? (1)

If yes, which services are available elsewhere, and where? (2)

The patient will be referred to:

(Name of the health care professional, entity, or health care facility)

for (Type of service)

PATIENT REQUEST FOR AND CONSENT TO OUT OF NETWORK REFERRAL

I have reviewed the information provided above and understand that:

I have the choice of using a participating health care facility/provider. If I choose to use a doctor or health care facility that does not participate in my network, my health insurance may not cover the services if my plan does not have out-of-network benefits. If my plan has out-of-network benefits, I understand that by using my out-of-network benefits I may have higher out-of-pocket costs that I will be responsible to pay. I hereby request and consent to my referral to the provider named above.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient signature

Date

PHYSICIAN DISCLOSURE OF FINANCIAL INTEREST

• In compliance with the requirements of law, you are being advised that I/we have a direct financial interest in the diagnostic or treatment agency or in the non-routine goods or services named above. If these goods/services we have prescribed are available elsewhere on a competitive basis, those other providers are listed above.

• I/we have a financial interest in the health care professional or health care facility listed above, or I may benefit by referring you to this health care professional or health care facility.

I have reviewed this form with the patient prior to treatment for which the referral is being made and the patient has acknowledged the information contained in this form and was offered a copy for his/her records.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Physician Signature

Date

PATIENT ACKNOWLEDGMENT OF FINANCIAL INTEREST

• I have the choice to use a health care provider in which my physician does not have an ownership interest, provided such a health care provider is available. I wish to utilize a health care provider in which my physician has an ownership/investment interest, as described in this disclosure form.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient signature

Date

Your information will be encrypted.