Rheumatology - Dr. Mary Olsen, MD
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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
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
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
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
Please list the names of other practitioners you have seen for this problem:
Please list all the locations of your pain on your body over the past week.
At any time have you or a blood relative had any of the following? (check if “yes”)
As you review the following list, please check any problems, which have significantly affected you:
If you checked Morning stiffness, How long it lasts?
If you checked Joint swelling, List joints affected in the last 6 mos.
Do you drink caffeinated beverages?
If Living
If Deceased
PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.)
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Acetaminophen
Codeine
Propoxyphene
Certolizumab
Golimumab
Hydroxychloroquine
Penicillamine
Methotrexate
Azathioprine
Sulfasalazine
Quinacrine
Cyclophosphamide
Cyclosporine A
Etanercept
Infliximab
Tocilizumab
Estrogen
Alendronate
Etidronate
Raloxifene
Fluoride
Calcitonin injection or nasal
Risedronate
Probenecid
Colchicine
Allopurinol
Tamoxifen
Tiludronate
Cortisone/Prednisone
Hyaluronan
Herbal or Nutritional Supplements
(Please check the appropriate response for each question.)
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.
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.
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?
Considering all the ways that your arthritis affects you, rate how you are doing.
*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.
For each category (ie, "Dressing & Grooming"), enter the highest number chosen in each row (0,1,2. or 3).
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.
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.
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.
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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