New Patient Registration Form

Rheumatology - Dr. Mary Olsen, MD

Please correct the errors described below.

Insurance Information

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Employment Information

Responsible Party Information

As the responsible party, I agree that all charges that are not directly paid by the insurance company will be my responsibility By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Payment of Benefits

I authorize payment of benefits, as determined by the insurance company, directly to the physician’s office. I understand that I still may be responsible for any amounts not paid by my insurance company. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Medical Release Authorization

I authorize any insurance company, organization, employer, hospital, physician, dentist, or pharmacist to release any information requested with regard to processing my claim. I certify that all information on this form is true and correct to the best of my knowledge. I know it is a crime to fill out this form with facts I know are false or to leave out facts I know are important. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Cancellation of Scheduled Appointments

I understand that if I have a serious emergency and I am unable to come to my appointment, I will contact the office as soon as possible. In other cases, if I fail to cancel my appointment 24 business hours in advance, I will be charged $50.00 for the missed appointment. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Patient History Form

Please list the names of other practitioners you have seen for this problem:

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Please list all the locations of your pain on your body over the past week.

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Rheumatologic (Arthritis) History

At any time have you or a blood relative had any of the following? (check if “yes”)

Systems Review

As you review the following list, please check any problems, which have significantly affected you:

For Women Only:

If you checked Morning stiffness, How long it lasts?

If you checked Joint swelling, List joints affected in the last 6 mos.

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Social History

Do you drink caffeinated beverages?

Past Medical History

Previous Surgeries

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Family History

If Living

If Deceased

Medications

PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.)

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PAST MEDICATIONS: Please review this list of “arthritis” medications. As accurately as possible, try to remember which medications you have taken, how long you were taking the medication, the results of taking the medication and list any reactions you may have had. Record your comments in the spaces provided.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Pain Relievers

Acetaminophen

Codeine

Propoxyphene

Disease Modifying Antirheumatic Drugs (DMArDS)

Certolizumab

Golimumab

Hydroxychloroquine

Penicillamine

Methotrexate

Azathioprine

Sulfasalazine

Quinacrine

Cyclophosphamide

Cyclosporine A

Etanercept

Infliximab

Tocilizumab

Osteoporosis Medications

Estrogen

Alendronate

Etidronate

Raloxifene

Fluoride

Calcitonin injection or nasal

Risedronate

Gout Medications

Probenecid

Colchicine

Allopurinol

Others

Tamoxifen

Tiludronate

Cortisone/Prednisone

Hyaluronan

Herbal or Nutritional Supplements

Activities of Daily Living

Because of health problems, do you have difficulty:

(Please check the appropriate response for each question.)

How does your condition affect everyday activities?

Fill out this form to assess how your condition may be impacting your daily life, and share the answers with your doctor. He or she may find the information useful when evaluating your condition and discussing treatment options.

Health Assessment Questionnaire-Disability Index*

Please choose the response that best describes your usual abilities over the past week:

Dressing & Grooming - Are you able to :

Arising - Are you able to :

Eating - Are you able to :

Walking - Are you able to :

Note to physician: The following aids and categories correlate to the activities listed above. If an item below is selected, and its corresponding activity (listed above) has been scored a 1, it will change to a 2.

Hygiene - Are you able to:

Reach - Are you able to:

Grip - Are you able to:

Activities - Are you able to:

Note to physician: The following aids and categories correlate to the activities listed above(Hygiene through Activities). If an item below is selected, and its corresponding activity (listed above) has been scored a 1, it will change to a 2.

We are also interested in learning whether or not you are affected by pain because of your illness. How much pain have you had because of your condition in the PAST WEEK?

0 (No Pain) - 100 (Severe Pain)

Considering all the ways that your arthritis affects you, rate how you are doing.

0 (Very Well) - 100 (Very Poor)

*The Health Assessment Questionnaire (HAQ) Disability Index was developed by James F. Fries, MD, and colleagues at Stanford University and measures disability with the use of aids and devices. It is scored on a scale of 0-3 units. A score of 0 indicates the lack of any measurable degree of disability, whereas a score of 3 means that a patient is unable to perform all activities.

This Section is For Physician Use Only

For each category (ie, "Dressing & Grooming"), enter the highest number chosen in each row (0,1,2. or 3).

Cancellation Policy/No Show Policy

For Doctor Appointments and Surgery

1. Cancellation/ No Show Policy for Appointment

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book. If an appointment is not cancelled at least 24 hours in advance you will be charged a fifty-dollar ($50) fee; this will not be covered by your insurance company.

2. Scheduled Appointments

We understand that delays can happen however we must try to keep the other patients and doctors on time. If a patient is 15 minutes past their scheduled time we may have to reschedule the appointment.

3. Cancellation/ No Show Policy for Surgery

Due to the large block of time needed for surgery, last minute cancellations can cause problems and added expenses for the office. If surgery is not cancelled at least 10 days in advance you will be charged a two hundred dollar ($200) fee; this is will not be covered by your insurance company.

4. Account balances

We will require that patients with self-pay balances do pay their account balances to zero (0) prior to receiving further services by our practice. Patients who have questions about their bills or who would like to discuss a payment plan option may call and ask to speak to a business office representative with whom they can review their account and concerns. Patients with balances over $100 must make payment arrangements prior to future appointments being made. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

(Office Use Only)

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