Version 11        1/24/09       copyright D. Waldman 2009

MARSHALL ORTHOPAEDICS / PATIENT HISTORY

MEDICAL HISTORY…[for yes/no or multiple type choices, circle just one]

 

BEST PHONE NUMBER TO REACH YOU : ______________________    TODAY’S DATE: ___________

 

NAME : ____________________________________________    HEIGHT : ______     WEIGHT:________

 

SS # :___________________    DATE OF BIRTH : ________________   AGE : __________________

 

REASON FOR VISIT [please give brief description—and which side !]_____________________________________

 

_______________________________________________________________________________

 

RESULT OF MOTOR VEHICLE ACCIDENT? yes   no         IS THIS WORK RELATED ?   yes   no

 

OTHER TYPE OF ACCIDENT?  yes    no    DATE OF ACCIDENT : _________________________

 

BRIEF DESCRIPTION OF ACCIDENT: ________________________________________________

 

___________________________________________________________________________________

 

ALLERGIC TO ANY MEDICINES?   yes    no   IF SO, WHICH ONES ?:_______________________

 

_________________________________________________________________________________

 

CURRENTLY TAKING ANY MEDICINES?  yes  no  IF SO, PLEASE LIST THEM ON ATTACHED PAGE

 

PAST SURGERY : __________________________________________________________________

 

ANY HEART, LUNG, OR KIDNEY DISORDERS ?  yes  no IF SO, WHAT KIND ? _____________

 

_________________________________________________________________________________

 

ARE YOU? :  right handed    left handed     SMOKER ? : yes   no   HOW MANY PACKS A DAY?:_____

 

DO YOU DRINK ALCOHOL?  no    rarely   socially   daily

 

Has any DOCTOR ever told you "Don't take arthritis medicine" ??     yes    no

_______________________________________________________________________________

CIRCLE CORRECT ANSWER PLEASE

TAKE BLOOD THINNERS ? :    yes    no             DIABETIC ?:     yes    no      

 

SUFFER FROM GOUT ? :   yes    no       HIGH BLOOD PRESSURE ?:     yes   no

 

TAKING CORTISONE BY MOUTH ?:    yes    no                                  HAD A BLOOD CLOT IN LEGS ?:    yes    no

 

HAVE AN ARTIFICIAL HEART VALVE ?    yes   no            HAD A HEART ATTACK OR BYPASS ?:    yes    no

 

HAD CANCER ?: yes   no        HAVE AIDS/HIV ?:  yes   no                     HAD A STROKE ?:    yes    no 

 

HAD EPILEPSY OR SEIZURES ?:    yes   no           EVER HAD HEPATITIS ?:    yes    no

 

HAD PROBLEMS WITH ANESTHETICS FOR SURGERY ?:    yes    no 

 

NAME OF YOUR FAMILY DOCTOR ? ________________________________________

 

FOR WOMEN:  ARE YOU PREGNANT OR POSSIBLY PREGNANT?   yes   no   uncertain

 

Had HYSTERECTOMY?    Yes    No                                Had TUBAL LIGATION ?     Yes      No

 

 

 

 

 

 

 

WHAT MEDICINES DO YOU TAKE ?  PLEASE WRITE THEM HERE, ONE MEDICINE PER LINE, PLEASE

 

YOUR NAME: __________________________       TODAY’S DATE:__________________

 

_____________________      __________________                                         _____________        ________________

name of medicine                                          dosage [“20 mg”, for example]                                         how often?                                from which doctor?

 

 

 

_____________________                  __________________                    ________________        ____________________

name of medicine                                          dosage [“20 mg”, for example]                                         how often?                                from which doctor?

 

 

 

_____________________                  __________________                     ________________        ____________________

name of medicine                                          dosage [“20 mg”, for example]                                         how often?                                from which doctor?

 

 

 

_____________________                  __________________                     ________________        ____________________

name of medicine                                          dosage [“20 mg”, for example]                                         how often?                                from which doctor?

 

 

 

_____________________                  __________________                     ________________        ____________________

name of medicine                                          dosage [“20 mg”, for example]                                         how often?                                from which doctor?

 

 

 

_____________________                  __________________                     ________________        ____________________

name of medicine                                          dosage [“20 mg”, for example]                                         how often?                                from which doctor?

 

 

 

_____________________                  __________________                     ________________        ____________________

name of medicine                                          dosage [“20 mg”, for example]                                         how often?                                from which doctor?

 

 

 

_____________________                  __________________                     ________________        ____________________

name of medicine                                          dosage [“20 mg”, for example]                                         how often?                                from which doctor?

 

 

 

_____________________                  __________________                     ________________        ____________________

name of medicine                                          dosage [“20 mg”, for example]                                         how often?                                from which doctor?

 

 

 

_____________________                  __________________                     ________________        ____________________

name of medicine                                          dosage [“20 mg”, for example]                                         how often?                                from which doctor?

 


PATIENT REGISTRATION

When registering, please show us proof of insurance, Medicare, or Medicaid.  The law requires us to collect any co-pay or deductible amounts due at the time of your visit.  If your insurance is not a PPO, then we also collect the patient’s share of what your insurance does not cover at the time of your visit.  This includes deductibles that are not met.  Payment in full is expected at the time of your visit if you have no insurance coverage.  We appreciate your understanding and cooperation.

YOUR NAME : _________________________________________________________________

 

YOUR ADDRESS : ________________________________________________________________

 

CITY : _______________________________    STATE : _______________    ZIP CODE : ___________

 

PHONE : _____________________________      CELL PHONE : _____________________________

 

MARITAL STATUS : ____________________   DRIVERS LICENSE NUMBER [& STATE]___________________________

 

EMPLOYER NAME / ADDRESS / PHONE : ____________________________________________________________________

 

________________________________________________________________________       STUDENT ?:  yes   no

 

PAYMENT METHOD :    ___ CASH     ___ CHECK      ____MASTERCARD       ____VISA

 

WHO REFERRED YOU TO OUR OFFICE ? ________________________________________

 

SPOUSE/GUARDIAN NAME: ____________________________________________________________

 

RELATIONSHIP TO PATIENT : ________________________________________________________

 

THEIR ADDRESS/CITY/STATE/ZIP :____________________________________________________

 

THEIR DATE OF BIRTH : _____________   THEIR SS #: __________________    THEIR DRIV. LIC #:_________________

 

THEIR EMPLOYER NAME/ADDRESS/PHONE : ___________________________________________________

________________________________________________________________________________________

RESPONSIBLE PARTY [IF OTHER THAN PATIENT]   …if it is your spouse, skip this section and go to emergency contact section

 

NAME : ____________________________________     PHONE : ___________________    CELL : ______________

 

ADDRESS/CITY/STATE/ZIP : ______________________________________________________________________

 

THEIR DATE OF BIRTH : _____________   THEIR SS #: __________________    THEIR DRIV. LIC #:_________________

 

THEIR EMPLOYER NAME/ADDRESS/PHONE : __________________________________________________________

___________________________________________________________________________________________

EMERGENCY CONTACT [someone not living with you]

 

NAME : ________________________________________     PHONE : ___________________    CELL :____________

 

ADDRESS/CITY/STATE/ZIP : _______________________________________________________________________


WAIVER

I understand and agree that health and accident insurance policies are an arrangement between my insurance company and me…not between my insurance company and this office.  I agree to pay my estimated co-pay at the time services are rendered, including any deductibles.  I understand that the estimated co-pay is neither a guarantee of payment by my insurance company, nor an accurate reflection of my actual co-pay as determined by my insurance company when they process my claim[s].  If my insurance company does not pay on my charges with 30-45 days from receipt of my claim, or within a reasonable period of time, upon request of this office I will immediately pay the balance owing on my account.  I understand that balances due over 60 days will be turned over to the Credit Bureau for collection.  I further understand and agree that if this office must take any action to collect an outstanding balance on my account, I will be responsible for payment, and will reimburse this office for all costs of such collection efforts including but not limited to all court costs and attorney fees.

I authorize this office to release any medical information relating to my treatment to any insurance company [ies] that may be responsible for paying benefits to me, and to any attorney who may be representing me due to my condition, and to complete any usual and customary reports and forms to assist in collecting from my insurance company [ies], attorney [s], or other payer [s].

I hereby authorize payment of benefits to be paid directly to:

DOUGLAS E. DUNCAN, M.D.

DOUGLAS A. WALDMAN, M.D.

I have read, understood, and agree to the foregoing.  The information which I have provided is true and complete to the best of my knowledge.

 

SIGNATURE OF PATIENT, OR PARENT/GUARDIAN: √________________________________  DATE : __________________________

 

 

FINANCIAL POLICY

Most insurance companies will only reimburse for services that THEY determine are medically necessary or deemed reasonable and necessary under their individual policies.  Should you insurance company determine that a particular service does not meet the criteria under your particular plan :

THE CHARGES WILL THEN BECOME YOUR PAYMENT RESPONSIBILTY

Should you have any questions about your insurance plan coverage and/or policy provisions, and what is or is not covered, we suggest that you check with your insurance company or your plan administrator with your employer.

I ACKNOWLEDGE FULL FINANCIAL RESPONSIBILITY, REGARDLESS OF MY INSURANCE STATUS, FOR PROFESSIONAL SERVICES RENDERED BY DOUGLAS E. DUNCAN, M.D. or DOUGLAS A. WALDMAN, M.D.

I MUST PAY MY PORTION PRIOR TO THE OFFICE VISIT, WHICH INCLUDES CO-PAYS AND DEDUCTIBLES, AT THE TIME THAT SERVICES ARE RENDERED.

I AM RESPONSIBLE FOR INSURANCE CLAIM DENIALS RESULTING FROM PRE-EXISTING CONDITIONS, UNCOVERED SERVICES, OR OTHER SERVICES DEEMED MY RESPONSIBILITY.

I MUST PAY MY PORTION OF HOSPITAL CHARGES WITHIN 30 DAYS OF RECEIPT OF STATEMENT.

Payment plans for hospital charges must be pre-approved by the office manager.  ALL OTHER PAYMENTS ARE DUE AT THE TIME OF SERVICE.

 

SUBSCRIBER’S SIGNATURE : √__________________________________________________  DATE : _______________________

 

PATIENT’S SIGNATURE : ______________________________________________________  DATE : _____________________

 

PATIENT ATTENDANCE POLICY

I understand that I should arrive fifteen minutes before my scheduled appointment to check in.  If I arrive more than fifteen minutes after my scheduled appointment time, I may have to reschedule and my visit will be marked as a missed appointment.

Attending follow-up appointments is crucial to providing adequate treatment for medical problems.  If I miss three appointments without calling first to cancel or reschedule, then I will have to seek a new physician.  If I call to cancel or to reschedule an appointment, then I agree to do so as early as possible.

I understand that the doctors in this clinic are operating surgeons, and as such, their daily schedules can be disrupted at any time for the sake of patients needing immediate care for a condition more serious or emergent than mine.  I understand that the doctors will do their best to see me on time, but that circumstances beyond their control often force them to run late or to cancel appointments altogether.  I UNDERSTAND THAT PRESCRIPTIONS CAN BE REFILLED ONLY DURING REGULAR OFFICE HOURS.

 

PATIENT : ______________________________________________________   DATE : ___________________________

 

GUARANTOR :___________________________________________________   DATE : __________________________

 

WITNESS : ______________________________________________________    DATE: ____________________________

 


MARSHALL ORTHOPAEDICS

Consent to the Use and Disclosure of Health Information for Treatment, Payment or HealthCare Operations.

 

PATIENT : ______________________________________________________________________________

 

HEALTHCARE PROVIDER :    D. Duncan, MD              D. Waldman MD                     

I understand that as part of my health care, Marshall Orthopaedics [MO] originates and maintains health records describing my health history, symptoms, examination, test results, diagnoses, treatments, and any plan for future care and treatment.  This important information may be used and disclosed for my treatment, so that my physician can get paid, and for various uses related to my physician’s operations.

I understand that MO’s Notice of Information Practices has a more complete description of how my health information may be used and disclosed to carry out these treatments, payments, and health care operations.  I have the right to review the notice prior to signing this consent.  I understand that MO reserves the right to change those practices described in the Notice of Information Practices and, if it does so, the Notice of Information Practices will also change.  A copy of any such change is available to me upon my request.

I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations, and that MO is not required to agree to the restrictions that I request but if it does agree, it must comply with that agreement.

I have received a copy of MO’s Notice of Information Practices, and I hereby consent to MO using and disclosing my health information as described in the Notice of Information Practices, including any changes that this practice may adopt in the future.  I understand that I may revoke this consent in writing, except to the extent that MO has already taken action in reliance on this consent.

I request the following restrictions to the use or disclosure of my health care information:

______  Do not release my HIV test results

______  OTHER [specify in detail]: ____________________________________________________________

                                                      ___________________________________________________________

 

PATIENT OR PERSONAL REPRESENTATIVE : _______________________________________________________

 

                                                Relationship to patient : _______________________________________________

 

WITNESS : _________________________________        DATE SIGNED : _____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Douglas E. Duncan, MD

Douglas A. Waldman, MD

Marshall Orthopaedics

POLICY REGARDING COPIES OF X-RAY FILMS

 

To Our Valued Patients and Friends:

Due to legal and liability reasons, our office cannot release original x-ray films taken here.

We can get the hospital to make copies of your x rays for you.  The hospital charges $10 [ten dollars] per film, and it is the patient’s responsibility to pay.

If our doctors refer you to another physician, or if you want to see another physician for a second opinion, we ask that you please give us 48 [forty-eight] hours notice [two business days] if you need copies of your x-ray films.  This gives us time to take the original films to the hospital to get the copies made.

Thanks very much for understanding.

I have read the above policy and I understand that I will need to give 48 [forty-eight] hours [two business days] notice to Marshall Orthopaedics if I need copies of my x rays made.  I also understand that I will have to pay the hospital $10 [ten dollars] per film sheet in advance of having copies made.

 

__________________________________________________                         _____________________________________

Patient / Responsible Party                                                                                    Date

 

__________________________________________________                         ______________________________________

Witness                                                                                                                    Date

 

 

 

NO SHOW POLICY

 

If you find that you will have to miss your appointment here, please notify us as soon as possible, during office hours.

If you simply do not keep your appointment, without notifying us, we will add a $25 [twenty five dollar] charge to your account.

This charge will not be paid by your insurance company, and you will have to pay this charge before you can be seen here again.

If you miss three appointments, you are considered a “chronic no-show” and you may be expelled from our practice.  

If you consistently call and cancel or re-schedule your appointment, you could also face expulsion.

We understand that sometimes situations are beyond your control, and we will work with you as much as possible.  We have had to establish this policy because many patients just don’t show up, and cause problems for everyone

Our doctors have a very busy schedule.  Patients who simply do not keep their appointments, without notifying us before, cause great hardships for everyone.  Not only is our time wasted but, more importantly, medical care for another patient is delayed for no good reason.

Your signature below indicates that you understand and will comply with this policy.  Thank you very much.

 

______________________________________________              _______________________

Signature [patient or responsible party]                                                 [date]