New Patient Paperwork

PATIENT INFORMATION

Name

DOB

Address

Cell Phone

Home Phone

Other Phone

OK to Leave Msg?

Cell

Home

Other

E-mail

Emergency Name & Phone

RESPONSIBLE PARTY INFORMATION

(if different than patient)

Name

DOB

Cell Phone

Home Phone

Other Phone

INSURANCE INFORMATION

Is your complaint related to a work injury?

Yes No

Primary Medical Insurance

Please Select

Group (Employer) Individual Worker's Compensation Other

Insurance Company

Policy Holder Name

Policy Number

Group Number

Secondary Medical Insurance (if any)

Primary Care Physician

How did you hear about us?

If referred by a physician, please provide name:

CONSENT FOR CARE AND TREATMENT

I, (Please enter Name below) hereby agree and give my consent for Craig C. Callewart, MD, PA to furnish medical care and treatment considered necessary and proper in diagnosing or treating my physical condition. text

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

I hereby have a right to privacy under Health Insurance Portability and Accountability Act (HIPAA) regulations. I understand that Craig C. Callewart, MD, PA is committed to protect this information. A copy of our Privacy Notice will be provided to you upon request. By signing, you acknowledge that you have either obtained a copy of our Privacy Notice, received satisfactory clarification of particular conditions, or choose to obtain a copy at a later date.

RELEASE OF INFORMATION AUTHORIZATION

I give Craig C. Callewart, MD, PA authorization for the release of medical records and privacy information, which includes my personal health information, any medical conditions, and/or billing and financial information to the following:

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FINANCIAL POLICY

I hereby authorize Craig Callewart, MD, PA to furnish to any designated insurance company or attorney all information necessary to file a health insurance claim form, or to obtain reimbursement. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare and other government sponsored programs, private insurance, and any other health plans to Craig C. Callewart, MD, PA. I understand that I am financially responsible for all charges whether paid or not paid by my insurance company.

PAPERWORK AND NO-SHOW FEES

In today's medical world and given the type of illnesses our practice works with, the amount of paperwork and forms that need attending to is often overwhelming. Due to the time-consuming nature of filling out and managing insurance claims, disability forms, as well as other length forms, we (as with most medical offices) find it necessary to charge a nominal fee for this service.

If Dr. Callewart is required to fill out a form or dictate a note regarding a matter, our office will charge the following fees:

Disability or FMLA forms: $10.00 for 1st page and $5.00 each additional page.
Disability letter: $25.00-$40.00 depending on the length of letter and amount of time required to review chart.
Insurance forms: $5.00 per page.
Letter of medical necessity: $25.00
ONLY within your global period, there will be no charge for disability or FMLA paperwork

CHARGES FOR INSURANCE, DISABILITY, AND OTHER OFFICIAL FORMS (cont.)

We will do our best to expedite taking care of your requests, however the speed with which we will be able to do so is dependent on many factors, including how many forms we have pending at any given time. For this reason, please allow two weeks to process your request. If you require immediate service, which may require overtime work by our staff, a fee of $30.00 will be assessed. For any appointment that you either no-show or cancel within 24 hours. There will be a $20.00 fee assigned to your account.

If you need special assistance in any way, please let us know. We do our best to give individualized service so that every one of our patients feels special. If we are not meeting your expectations, please let us know how we can serve you better.

PRESCRIPTION POLICY

Dr. Callewart diagnoses and treats conditions of the spine. We may prescribe medications for you to help relieve the pain. These medications, when used properly, can help patients feel better and lead more productive lives. These medications can also be misused, causing harp to patients and others. For this reason, the State of Texas and the Federal Drug Enforcement Administration regulate the use of medications. Craig C. Callewart, MD, PA, follows those laws, and those laws became more restrictive in 2015. Additionally, Medicare has further restrictions.

Our Policy:

Written prescriptions will not be replaced if lost, stolen or misplaced, unless a police report is file
Prescriptions are to be taken as directed. Do not take more pills than the prescription states, or the insurance/pharmacy/DEA may not allow a refill.
Certain controlled substances such as Oxycontin, MS Contin, Percocet, and Hydrocodone are written for a maximum of 30 day supply. It is necessary to make monthly follow up appointments in order to receive a refill. Patients are subject to urine screening as outlined by State Boards. By law, these controlled substance medications cannot be refilled over the phone.
Refills for prescriptions listed below may be refilled every three months. As a result, if you were not seen in the hospital or office in the past three months, prescriptions cannot be refilled. A. Anti-inflammatories such as Celebrex B. Narcotics such as Tylenol #3 & Tylenol #4 C. Muscle relaxers such as Soma, Robaxin, or Flexeril
Craig C. Callewart, MD, PA will monitor your pain medication intake for your health and safety. Patients placed on opioid therapy and/or narcotics will be subject to drug screening at Craig C. Callewart MD, PA's discretion.
If your prescription bottle indicates that you have refills remaining, contact your pharmacy directly If there are no refills left, you will need to contact our office and schedule an appointment for a re-evaluation.
Refills cannot be authorized at night, on weekends, or holidays. Be sure to plan ahead to make sure you have enough medication.

PHARMACY INFORMATION

Pharmacy Name:

Phone:

Address (minimum crossstreet):

DISCLOSURE OF PHYSICIAN FINANCIAL INTEREST

Pursuant to Federal and Texas Law, I have been informed that either Craig C. Callewart, MD, PA or one or more of its affiliates, physicians, or owners have a financial interest in one or more of the following organizations: Baylor Medical Center at Uptown and Methodist Hospital for Surgery. We want you to know that you do have the option to use an alternative health care provider, should you choose.

ACKNOWLEDGEMENT AND AGREEMENT

By signing below, I acknowledge that I have read and agree to the above policies or information, including Financial Policy, Paperwork and No Show Fees, Prescription Policy, the Disclosure of Physician Financial Interest. I have been given an opportunity to ask questions, if any.

AUTHORIZATION FOR DISCLOSURE OF HEALTHCARE INFORMATION

I hereby authorize the disclosure of health information in any data format (including any images) regarding my treatment, hospitalization, and outpatient care to Callewart, Craig C , MD, PA. I understand that this facility will maintain medical records in accordance with state requirements and are hereby released from all legal respinsibility or liability that may arise from this authorization. By my signature below, you are fully authorized to disclose such information when requested by Callewart, Craig C , MD, PA

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

Patient Name:

DOB:

Patient Signature:

DESCRIBE THE PROBLEM

Please draw on the body diagram all areas of concern using the legend.

Ache: ^^^^^^^^

Numbness: =========

Pins/Needles: 000000000

Burning: XXXXXXXXX

Stabbing: //////////

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What do you want to happen as a result of this visit?

How and when did your problem begin? (Please mark each answer that applies to your neck/back pain.)

I don’t know how it began.

It comes and goes.

I’ve had it along time.

Injury

I've had it along time: years:

Injury: Date of Injury

On the job?

Yes No

Please explain how the injury happened.

MEDICAL HISTORY

Do you have any of the following problems? (Please check your answer.)

Is your pain worse at night?

Yes No

Does your pain awaken you from sleep?

Yes No

Does coughing affect your pain?

Yes No

Do your legs tire/hurt if you walk too far?

Yes No

If YES, how far can you walk?

less than 1 block 1-3 blocks more than 3 blocks

Is this relieved by resting your legs?

Yes No

Is this relieved by bending forward?

Yes No

Bladder Control (urine):

No problem Can't empty bladder Loss of urine (accidents)

How does each of the following affect your pain? (check your answer)

Sitting

Better Worse No Change

Standing

Better Worse No Change

Walking

Better Worse No Change

Lying down

Better Worse No Change

Rising from chair

Better Worse No Change

Physical activity

Better Worse No Change

Heat

Better Worse No Change Don't Know

Cold

Better Worse No Change Don't Know

We need to know about the treatments you have already received for your current back/neck pain. If YES, did it make your condition better or worse?

Have you had:

Chiropractic care

Better Worse

Physical therapy

Better Worse

Injections

Better Worse

Psychological consultation

Better Worse

Other:

Better Worse

Other:

For your current back/neck pain, please mark the boxes for the timeframe that any tests were done.

X-rays

< 6 months < 12 months

MRI scan

< 6 months < 12 months

CT scan

< 6 months < 12 months

Myelogram

< 6 months < 12 months

Discogram

< 6 months < 12 months

EMG/NCV(nerve test)

< 6 months < 12 months

Have you ever had surgery on your back or neck?

Yes No

If YES, complete the following:

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GENERAL MEDICAL HISTORY

Check all the conditions below that you have currently or have had in the past.

If NONE check

If Cancer is select, Type:

Other:

MEDICATION LIST

Allergies / Intolerances:

Other Medications

Check All Surgeries That Apply

Other:

SOCIAL HISTORY

Marital Status

Married Separated Divorced Single Widow/Widower

Education (Check the highest level completed:)

Grammar school High school College Post-graduate

Smoking

Current Every Day Smoker Current Some Day Smoker Former Smoker Never Smoker

Year Smoked

Smokeless / Chewing

Amount per day

Alcohol

Do you drink:

Frequency of drinking:

never rarely socially daily

Amount drinks per day

Do you have a history of heavy drinking?

yes no

Effect of your back/neck pain on your lifestyle.

My home setting is supportive of me during this time.

Yes No

My work setting is supportive of me during this time.

Yes No

My pain has affected my interaction with my family and friends.

Yes No

The changes in my lifestyle due to my problem have been difficult for me.

Yes No

What is your ability to enjoy life?

Excellent Very good Good Fair Poor

Household Situation - Who Lives There (Circle all that apply)

Live Alone

With Spouse/Adults

With Children less than 12 y.o.

Disable Person

Diet: (Circle all that apply)

Regular

High Protein

Vegetarian

Other:

Other

Supplements: (Circle all that apply)

Calcium

Vitamin C Vitamin D Vitamin E Fish Oil

Tumeric

Ginger

Other

Current Employment: (Circle all that apply)

Desk Job Computer

Standing

Walking

Stairs

Lifting

Pushing

Pulling

Overhead

Walking

REVIEW OF SYSTEMS

In the past month, have you had any of the following problems?

GENERAL

Chills

Fatigue/Weakness

Malaise

Poor Weight Gain

Weight Loss

Night Sweat

EYES

Vision Loss

Visual Disturbance

EAR/NOSE/THROAT

Difficulty Swallowing

Sinus Pressure/Pain

Tinnitus

CARDIOVASCULAR

Chest Pains

Palpitations

FAMILY MEDICAL HISTORY

I do not know the medical history of my biological parents or other family members. (Go on to next section.)

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Members of my family (parents, brothers/sisters, grandparents, aunts/uncles) suffer with the following:

Other:

ORTHOPEDIC SIGNIFICANT HISTORY (YOU OR YOUR FAMILY)

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