pdf testadmin2023-06-06T07:47:11+00:00 Step 1 of 7 14% PATIENT HISTORYFirst Name(Required) Last Name(Required) Hand Dominance: Right Left Height Weight Primary Care Physician Who referred you to our clinic? Do you see any other medical specialists (i.e., cardiologist, etc.)?If yes, please list: Yes No If yes, please list: Pharmacy name and address Date of Injury(Required) MM slash DD slash YYYY How did the injury occur? Where did the injury occur? Injury result of:(Required) Sports Auto Accident *On the Job If on the job, is it Workers’ Comp? Yes No Signature(Required) Injury Location Right Left Injury Location Where? Shoulder Elbow Hand Hip Knee Foot Arm Wrist Finger Leg Ankle Toe Injury Location Where? Shoulder Elbow Hand Hip Knee Foot Arm Wrist Finger Leg Ankle Toe What symptoms are you experiencing? Locking Grinding Catching Weakness Popping Numbness Stiffness Other Other symptoms Pain Level (0-10; 10 being severe pain) Have you ever had Physical Therapy for this issue? Yes No What increases your pain? Have you had Chiropractic Treatment? Yes No Have you had any studies or testing for this injury? X-ray MRI CT EMG/NCV Other Other testing for this injury Place of these studies Date of these studies MM slash DD slash YYYY Medical History(Please include any medical conditions you have been treated for)Medical History Option AIDS/HIV Alcoholism Alzheimer’s Anemia Rheumatoid Arthritis Asthma Blood Clot Leg Blood Clot Lung Stroke Osteogenesis Imperfecta Other Disease(s) Medical History Option Cancer - Breast Cancer - Colon Cancer - Lung Cancer - Prostate COPD Depression Diabetes Drug Abuse Sleep Apnea Medical History Option Gout Heart Attack Hypertension Hepatitis Kidney Disease Osteoarthritis Seizures Ulcers, Bleeding Blood Thinners (Plavix, aspirin, etc.) Other Disease(s) Past Surgies/Dates Family History(If family condition exists, please write “father”, “mother”, or “sibling” after condition)Family History Option AIDS/HIV Anemia Blood Clots Cancer Coronary Artery Disease Rheumatoid Arthritis Family History Option Diabetes Gout Heart Attack Hemophilia Hypertension Other Family History Option Kidney Disease Liver Disease Muscle Disease Osteoporosis Osteoarthritis Other Family History FEMALES ONLYCould you be pregnant? Yes No Social History(Please indicate use/former use of the following substances)Tobacco Yes No Former Alcohol Yes No Caffeine Yes No Illicit Drugs Yes No I DON’T USE ANY OF THESE I DON’T USE ANY OF THESE List all current medications and dose (include non-prescription and herbal supplements) None List Attached List Attached Option Do you have any allergies to any medications or substances? Review of Systems (Please indicate if you experience any of the following)Constitutional Weight Loss/Gain Weakness Fatigue Fever Cardiovascular High Blood Pressure Chest Pain Rheumatic Fever Palpitations Have Pacemaker Musculoskeletal Joint Pain Arthritis Muscular Weakness Stiffness Muscular Pain Endocrine Thyroid Trouble Excessive Sweating Excessive Thirst Eyes Glasses or Contacts Blurred Vision Glaucoma Cataracts Excessive Tearing Respiratory Shortness of Breath Cough Wheezing Asthma Bronchitis Skin Rashes Sores Lumps Dryness Itching Hematolymphatic Anemia Easy Bruising Easy Bleeding Swollen Glands Ear/Nose/Mouth/Throat Ears Ringing Earaches Hearing Aid Frequent Colds Nasal Discharge Hay Fever Nosebleeds Dentures Bleeding gums Frequent Sore Throats Gastrointestinal Heartburn Rectal Bleeding Abdominal Pain Gallbladder trouble Hepatitis Neurologic Headache Dizziness Seizures Loss of Sensation Vertigo Immunologic Reactions to Drugs Skin Rashes Reactions to Foods Genitourinary Blood in Urine Urinary Infections Kidney Stones Burning Urination STDs Psychiatric Nervousness Depression Mood Change HiddenCONSENT FOR TREATMENTCONSENT FOR TREATMENT: To the best of my knowledge, the questions on this form have been answered accurately. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor of any changes in my medical status. I also authorize the health care staff to perform the necessary services I may need.Signature of Patient or Parent of Minor(Required) Date MM slash DD slash YYYY Patient DemographicDate(Required) MM slash DD slash YYYY Age Gender Male Female Patient Name(Required) Address(Required) City State Zip Home Phone(Required)MobileEmail Social Security Number Date of Birth(Required) MM slash DD slash YYYY Race Ethnicity Primary Language Employer/School Occupation Employer/School Address & Phone Marital Status Single Married Widowed Divorced RESPONSIBLE PARTYLegal Name(Required) Relationship to Patient Social Security Number Date of Birth MM slash DD slash YYYY Address Phone NumberEmployer Name & Phone EMERGENCY CONTACTLegal Name(Required) Relationship Address City State Zip Home PhoneMobileFAMILY ACCOUNTSDo you have other family members in your household being treated at ABJC? Yes No Name and Birthdate(s) INSURANCE INFORMATIONInsurance Company(Required) Policy Holder’s Name/Relationship(Required) Date of Birth(Required) MM slash DD slash YYYY Policy #(Required) Group #(Required) Name as it appears on insurance card(Required) Secondary Insurance Policy Holder’s Name/Relationship Date of Birth MM slash DD slash YYYY Policy # Group # Name as it appears on insurance card I authorize release of any medical or other information necessary to process this claim, including the appeal of claims for payment on my behalf. I understand that services rendered today are my financial responsibility. Insurance is filed as a courtesy to you; there may be a difference between your benefits and fees. I assign payment of medical benefits to: Amarillo Bone & Joint Clinic, J. Brian Sims, MD, PA, Brad Veazey, MD, PA, Toby Risko, MD, PA, Joshua North, MD, PA, Todd Bradshaw, MD, PA, and/or Creed Paris, MD, PA. HiddenI authorize release of any medical or other information necessary to process this claim, including the appeal of claims for payment on my behalf.Signature(Required) Relationship RELEASE OF INFORMATIONPatient Name(Required) Date of Birth(Required) MM slash DD slash YYYY Please list the names of any family members, friends or any other person that we may release information to, such as: general medical condition including treatment, prescriptions to be picked up at our office if you were unable to come by, medical records, school notes, etc. Please note: for children under the age of 18- to the parent filling out patient paperwork, please list the second parent on this form if they will need access to the patient’s information.HiddenPlease list the names of any family members, friends or any other person that we may release information to, such as:Name Name Name Name Name Name Signature(Required) Date MM slash DD slash YYYY Authorization for the Disclosure of Health InformationPatient Name(Required) Date of Birth(Required) MM slash DD slash YYYY Social Security Number Telephone Number Address City State Zip I hereby authorize and request Amarillo Bone & Joint Clinic, LLP to provide to receive from I hereby authorize and request Amarillo Bone & Joint Clinic, LLP to Specify date(s) of Encounter(s)/Hospitalization(s) The type and amount of information to be used or disclosed is as follows:The type and amount of information to be used or disclosed is as follows: Complete Medical Record Physician’s Office Progress Notes Photographs, Videotapes, Digital or other images The type and amount of information to be used or disclosed is as follows: History & Physical X-Ray Film(s) The type and amount of information to be used or disclosed is as follows: Operative Report Problem List Discharge Summary Other The type and amount of information to be used or disclosed is as follows Other reason with regard to(Patient Name) medical/hospital records for the purpose of:medical/hospital records for the purpose of: Continuity of Care Billing and Payment of Bill Other medical/hospital records for the purpose of (Other) I understand that this authorization can be revoked, in writing, at any time except to the extent that disclosure made in good faith has already occurred in reliance upon this authorization. This authorization shall expire one year after the date appearing below except for payment of all claims at which time this authorization may be in force greater than one year.This authorization is for full disclosure of all health data which may include any information related to care for my impairment(s) information about how my impairment(s) affects my ability to complete tasks and activities of daily living, information about how my impairment(s) affect my ability to work; and/or related to drug, alcohol, mental health, psychiatric conditions, and/or sexually transmitted disease, Sickle Cell anemia, including AIDS/HIV information [42 CFR part 2]. Such records will be disclosed unless you specify information that you wish to be excluded. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form to ensure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in 45 CFR 164.524. If I have questions about disclosure of my health information, I can contact Amarillo Bone & Joint Clinic, LLP. Facsimile transmission of this form will be deemed as having the same force and effect as an original. The risks associated with the use of facsimile transmission are understood. This form was read BY me was read TO me. I have been offered the opportunity to ask questions about this form, and I fully understand its contents and meaning. All blanks were filled in before the form was signed by me.Patient or Authorized Representative Signature(Required) Date MM slash DD slash YYYY If signed by Legal Representative, Relationship to Patient Witness Signature Date MM slash DD slash YYYY Interpreter's Statement (if Interpreter assisted):I have translated the information presented orally to the patient by: (Employee's Name) I have also read the Authorization for Disclosure of Health Information Form to: (Patient Name) in (language) Signature of Interpreter Date MM slash DD slash YYYY ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESI(Required) acknowledge that I have received a copy of the Amarillo Bone & Joint Clinic, LLP (AB&JC) Notice of Privacy Practices.Patient Signature(Required) Date MM slash DD slash YYYY Patient Legal Representative (if applicable) Date MM slash DD slash YYYY Print name of Legal Representative Relationship to patient Textarea Textarea HiddenFOR AB&JC USE ONLYAB&JC has made the following good faith efforts to obtain the above-referenced individual's written acknowledgement of receipt of the Notice of Privacy Practices: (Identify the efforts that were made to obtain the individual's written acknowledgement, including the reasons (if known) why the written acknowledgement was not obtained.) HiddenTextarea HiddenTextarea HiddenTextarea HiddenName of Office Representative HiddenDate Placed in Patient Chart FINANCIAL RESPONSIBILITIESWe are committed to providing you excellent care. Since payment of your bill is part of your treatment, we want to be sure that our financial policies are clearly understood. Payment is due at the time of service. Services not covered by insurance, including surgical assistants, deductibles, and co- insurance amounts, are due at the time of service. As a courtesy, we will submit your claim to your insurance company. Surgery deposits are required on all non-emergent procedures. Our deposits are based on estimates and patient responsibility may vary depending on the actual surgery/procedure and what your insurance pays. Payment of your account is your responsibility regardless of your insurance coverage. Your insurance is a contract between yourself and the insurance carrier. We are not a party to that contract. We do our best to verify your insurance coverage and benefits at the time of your visit, but it is your responsibility to check with your insurance provider to know what they cover and what providers are in your network. If claims for services provided by ABJC Clinic are denied by your insurance company, you are responsible for payment. Responsibility for payment begins on the date that services are provided. Notification of any change in your insurance status must be provided to the office forty-eight (48) hours in advance of next visit, or payment in full will be required. Surgery: Amarillo Bone & Joint Clinic strives to give you the most accurate surgery estimate based off the surgeon's anticipated procedure codes, your insurance benefits, and your insurance allowable. At times, due to findings during surgery, these procedure codes could change. These modifications could result in an additional balance. Final determination will be made by your insurance company. Assistant Surgeon: To give you the level of care needed; your surgeon deems it necessary to have an Assistant Surgeon during your surgery. Insurance companies cover some of these charges, however some are deemed as non-covered services under your policy. If your insurance company denies the Assistant Surgeon charges, you will be responsible for the balance at a courtesy reduced rate. Liability of Auto Accident Claims: We do not become involved in automobile or liability lawsuits, nor do we file liability claims or wait on “settlements”. You will be required to pay in full for services rendered. We will provide you with the necessary information to be reimbursed. You may contact the Billing Department for an itemization of your statement. Workers' Compensation: We do not participate in Workers’ Compensation and are unable to file claims on your behalf. We do not see patients for any work-related injuries. Refunds: Refunds will be assessed once all claims have processed on your account, and after you have been released from treatment from both the surgeon and Physical Therapy, if you are having physical therapy at ABJC. Balance: If you have a balance remaining after your insurance carrier has paid, and for our patients without insurance, we offer the following options: Extended Payment Plans: may be available upon application acceptance through Care Credit. Short Term Payment Plans: may be available on balances and cannot exceed three months. Financial Constraints: Patients who have other financial considerations should speak with our Financial Counselor for assistance. Our goal is to ensure that everyone in need receive appropriate care. Accounts with a remaining balance where no resolution has been made in a timely fashion may be turned over to a collection agency. I understand that I am financially responsible for payment of medical charges incurred on my behalf as outlined above. Signature(Required) Date MM slash DD slash YYYY
