patient information patient financial policy · home phone number day phone number cell phone...

LAST NAME FIRST NAME MIDDLE NAME PREVIOUS LAST NICKNAME

SOCIAL SECURITY BIRTHDATE SEX

BILLING ADDRESS STREET CITY STATE ZIP CODE

COUNTY RACE LANGUAGE ETHNICITY

MARITAL STATUS PRIMARY CARE PROVIDER

HOME PHONE NUMBER DAY PHONE NUMBER CELL PHONE NUMBER

ALTERNATE PHONE FOR EMERGENCY E-MAIL

PAYER NAME

ADDRESS CITY STATE ZIP CODE

PLAN NUMBER POLICY NUMBER

GROUP NAME GROUP NUMBER EFFECTIVE DATE

SIGNATURE DATE

Patient

Insurance

Financial Policy

1. Fees are due and payable at the time of your appointment. If we are contracted with your insur-ance, you will be billed any remainder after we hear from them. As a courtesy, we accept cash, checks, Visa, Discover, and Master Card.

2. If you have an HMO or PPO insurance with a designated primary care physician, please make

card or information, you will be required to pay the entire fee including any lab services.3. All co-pays must be paid at the time of your service4. Not all services are a covered benefit in all contracts. If you have a question regarding benefits,

insurance policy is a contract between you and your insurance company.5. All services must be paid in full within 30 days after your insurance has paid their portion. If your

visit is due to a Motor Vehicle Accident, payment in full is due at the time of the service. 6. The person who brings a child for care is ultimately responsible for their bill. The physician will

not get involved in court decisions or support disputes.7. Accounts become past due after 30 days. We reserve the right to send an account to collections

if not paid in full8. All returned checks must be paid with cash or money order within 5 working days or they will be

9. 10. All deductibles and co-payments for Obstetric (OB) services must be paid in full by the 7th month

with regular payments due each month by cash, check or credit card.

I hereby acknowledge that I have read, understand, and agree to the terms of this document relating

to insurance coverage and payment of my bill.

PATIENT/GUARDIAN’S SIGNATURE PRINT PATIENT’S NAME & BIRTH DATE DATE

Signature On File

I authorize use of this form on all my insurance submissions. I authorize release of information to all of my insurance companies. I authorize direct payment to The Liberty Clinic. I permit a copy of this authorization to be used in place of the original. I understand I am financially responsible for all

charges whether or not covered by insurance.

SIGNATURE DATE

Patient InformationPATIENT NAME: PREFERRED NAME:

GENDER: MALE FEMALE DOB: / / AGE: SINGLE MARRIED WIDOW

RACE: (CIRCLE ONE) AMERICAN INDIAN ASIAN BLACK NATIVE HAWAIIAN WHITE UNKNOWN

ETHNICITY: (CIRCLE ONE) HISPANIC NON-HISPANIC UNKNOWN/NOT LISTED LANGUAGE:

ADDRESS: CITY: STATE: ZIP:

SSN# / /

HOME PHONE: CELL: EMAIL:

PATIENT’S EMPLOYER: OCCUPATION:

EMPLOYER ADDRESS: PHONE:

SPOUSE NAME: EMPLOYER: OCCUPATION:

EMPLOYER ADDRESS: PHONE:

EMERGENCY CONTACT (RELATIONSHIP): PHONE:

REASON FOR CONSULT: LEFT/RIGHT/BOTH (LIST BODY PARTS)

REFERRED BY: (FIRST AND LAST NAME OF PHYSICIAN OR HOSPITAL)

FAMILY PHYSICIAN: SEND RECORDS TO THIS PROVIDER? YES NO

PRIMARY INSURANCE: ID#:

GROUP# CO-PAY: $

POLICY HOLDER: SSN#: / / DOB:

SECONDARY INSURANCE: ID#:

GROUP#: CO-PAY: $

POLICY HOLDER: SSN#: / / DOB:

IF PATIENT IS A MINOR-PLEASE COMPLETE

PARENT/GUARDIAN: PHONE: WORK:

EMPLOYER:

ADDRESS:

WHO DOES THE MINOR LIVE WITH?

WORK COMP INFO AUTO ACCIDENT INFO OTHER INJURY INFO

DATE OF ACCIDENT: / / SUPERVISOR: PHONE:

BILLING ADDRESS: STATE:

AGENT: INSURANCE: CLAIM#:

ADDRESS:

MEDICAL INSURANCE INFORMATION (GIVE INSURANCE CARD TO RECEPTIONIST)

Santosh George, M.D.Joshua J Niemann, M.D.Ryan R Snyder, M.D.Leslie D. �omas, M.D.Brett L Wilson, PA-C

2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068

P 816-781-6066 F 816-792-5130 www. libertyhospital.org

Board Certified Diplomats of the American Board of Orthopaedic Surgery

ORTHOPEDICSURGEONS CLINIC

T H E

An affiliate of Liberty Hospital

TOSC-001 1








PAYER NAME




SIGNATURE DATE

Patient

Insurance

Financial Policy













Signature On File



SIGNATURE DATE

Comprehensive Health History

Have you ever, or do you:

SMOKE yes no Packs per day Age quit Any smokers in the home? yes no

SMOKELESS TOBACCO yes no quit How much? Year quit

DRINK ALCOHOL yes no What forms? Quantity Frequency

ILLICIT DRUGS yes no What forms? Quantity Frequency

ALLERGIES (medication & food) No known medication allergies No known food allergies

List all medication and food allergies, please identify reaction

Are you allergic to latex or latex based products?

See attached list

yes no

CAFFEINE USAGE yes no Co�ee Tea Soda Daily Amount

Tape? yes no Iodine? yes no

MEDICATIONS

Medication Dose How often do you take Medication Dose How often do you take

FAMILY HISTORY

Are your parents living? Mother yes no Father yes no Cause of death?

Please list any health conditions/serious illnesses that your mother, father, sister(s) or brother(s) have or have been told they have

had in the past (i.e. diabetes, heart condition, high blood pressure, stroke, high cholesterol, cancer, thyroid, etc.)

Father

Mother

Sister(s)

Brother(s)

PATIENT FULL LEGAL NAME DATE OF BIRTH




Board Certified Diplomates of the American Board of Orthopaedic Surgery


T H E


TOSC-001 2

PATIENT PAST SURGICAL

Angioplasty (heart cath) year Cataract extraction year Lasik year

Angio (heart cath) w/stent year Gallbladder surgery year Liver biopsy year

Appendectomy year Colectomy (colon resection) year ORIF (fracture repair) year

Arthroscopy knee year Colostomy year Pacemaker year

Back surgery year Gastric bypass year Small bowel resection year

CABG (heart bypass) year Hernia repair year Thyroidectomy year

Carpal tunnel release year Hip/Knee replacement year Tonsillectomy year

Other

PATIENT PAST SURGICAL Women only

Augmentation mammoplasty (implants) year D & C year Myomectomy (Fibroidectomy) year

Bilateral tubal ligation year Hysterectomy (abdominal) year Reduction mammoplasty year

Breast Biopsy year Hysterectomy (vaginal) year Oopherectomy (ovary removal) year

Cesarean Section year Mastectomy year TAH/BSO year

Other

TOSC-001 3

PATIENT PAST MEDICALAllergies CHF (Conjestive Heart Failure) Immune system disorder

Anemia COPD (Chronic Obstructive Pulmonary Disease) Irritable bowel disease

Angina (chest pain) Coronary artery disease Liver disease

Anxiety Crohn’s disease

Migraine headaches

Arthritis

Depression

Myocardial infarction (heart attack)

Asthma

Diabetes

Osteoarthritis

Atrial fibrillation

Gallbladder Disease

Osteoporosis

Benign Prostatic Hypertrophy

GERD or chronic heartburn

Peptic ulcer disease

Blood clots locationP.E./DVTWhen:

Hepatitis A B C

Renal (kidney) disease

Cancer location

Hyperlipidemia (high cholesterol)

Seizure disorder

Cerebrovascular accident (stroke)

Hypertension (high blood pressure)

Thyroid high low other

Other

Have you ever had General Anesthesia? Any complications? Yes No

Malignant Hyperthermia

MRSA

Fibromyalgia

Blood clotting disorder






T H E


FIRST, MIDDLE, LAST:

HEMATOLOGIC

HemophiliaDeep Vein ThrombosisSickle Cell

Have you ever received a Blood Transfusion?

PATIENT SIGNATURE: DATE/TIME:

Yes No When?

IMMUNOLOGIC

HIV Infection/AIDSLupusImmunosuppressed (on chemo/transplant)Are you on predisone (Deltasone) Yes No

HERNIA

GroinBelly ButtonIncisional






T H E



TOSC-001 4








PAYER NAME




SIGNATURE DATE

Patient

Insurance

Financial Policy













Signature On File



SIGNATURE DATE

Review of Systems* (check yes or no if you currently are experiencing any of the following):

*Please inform the physician, medical assistant or front desk staffof any other medical conditions or concerns.

SYMPTOM YES NO

JOINT PAINS

JOINT SWELLING

JOINT STIFFNESS

UNSTEADY GAIT

NUMBNESS

TINGLING

UNEXPECTED WEIGHT LOSS

FEVER

CHILLS

POOR HEALING WOUNDS

SCARRING / KELOIDS

EASY BLEEDING

Alerts* (check yes or no for the following):

ALERT YES NO

PACEMAKER

BLOOD THINNER

DEFIBRILLATOR

PREMEDICATION PRIOR TO PROCEDURES

RHEUMATOID ARTHRITIS

RSD (REFLEX SYMPATHETIC DYSTROPHY)

ALLERGY TO SHELLFISH OR IODINE

ALLERGY TO LATEX

ALLERGY TO ADHESIVE

PAIN MANAGEMENT TREATMENT







T H E


TOSC-001 5

Santosh George, M.D.Joshua J. Niemann, M.D.Ryan R. Snyder, M.D.Leslie D. �omas, M.D.Brett L. Wilson, PA-C





T H E


TOSC-001 6

Patient Name

Adults I hereby give permission for the following individual(s) to pick up my prescription and / or other documents in my absence. To ensure proper handling of all controlled substances, I understand they will be required to show proper photo identification each time.

1.

2.

3.

4.

PHARMACY INFORMATION IN CASE A PHYSICIAN CAN PRESCRIBE THROUGH THIS AVENUE

PHARMACY NAME:

PHONE:

LOCATION:

No one other than myself (patient) has permission to pick up my prescriptions and /or other articles in my absence.

Date of Birth

SIGNATURE DATE

This form does not authorize releasing copies of my medical records.To the following people who are involved with my healthcare and/or payment information: (check all that apply and list names and telephone numbers) Spouse_________________________________________ Phone:__________________ Friend____________________________________________ Phone:__________________ Child(ren)_________________________________________ Phone:__________________ Other_____________________________________________ Phone:__________________ Do not release my information to anyone.I hereby allow The Orthopedic Surgeons Clinic to disclose the following information. (check all that apply) Appointment times and dates Medical information, including my symptoms, diagnosis, medications and treatment plan Tests that have been performed Test results Billing/payment information Other health information (describe)_____________________________________________

Can confidential messages (i.e. appointment information, prescription information, test results) be left on your answering machine or voicemail? (check how you wish to receive messages, and provide the phone number) No, DO NOT leave any messages Yes, at home, cell phone or work: Home Phone:__________________Cell Phone:__________________Work Phone:________________ Yes, only at home Home Phone:_______________________________ Yes, only on cell phone Cell Phone:_____________________________

I understand that in certain situations The Orthopedic Surgeons Clinic may speak to other individuals who are involved in my care or payment of that care, if permitted by law, that may not be identified on this form.

I understand that I have the right to revoke (stop) my permission at any time.

Patient Name (please print):_____________________________________ Date of birth:______________

Patient/Guardian Signature:_______________________________________Date:___________________

If patient is a minor, please complete the following information:Mother’s name/contact number:__________________________________________________________Father’s name/contact number:___________________________________________________________

Permission to Disclose Information to �ose Involved in My Care






T H E


TOSC-002

Permission to Disclose Information to Those Involved in My Care

I hereby allow The Orthopedic Surgeons Clinic to disclose the following Protected Health Information to the following people that are involved with my healthcare or payment (please mark each that you allow):

o Appointment times and dates o Tests that have been performed o Test results o Billing/payment information o Other health information

To the following people who are involved with my healthcare or payment information: (please mark all who apply and list his/her names and telephone numbers)

o Spouse________________________________________________ Phone:________________________________ o Friend_________________________________________________Phone:________________________________ o Child(ren)____________________________________________ Phone:________________________________ o Other__________________________________________________Phone:________________________________

May a con�idential message (i.e. appointment information, prescription information, test results) be left on your answering machine or voicemail (please circle how you wish to receive messages)?

Yes, at home, cell phone or work Yes, only at home Yes, only on cell phone No, DO NOT leave any messages Patient Name (please print):_____________________________________________Date:_________________ Patient/Guardian Signature:_____________________________________________ Date:__________________ If patient is a minor, please complete the following information: Mother’s name/contact number:_______________________________________________________________ Father’s name/contact number:________________________________________________________________






T H E


TOSC-005

Financial Policy













Signature On File

I authorize use of this form on all my insurance submissions. I authorize release of information to all of my insurance companies. I authorize direct payment to The Orthopedic Surgeons Clinic. I permit a copy of this authorization to be used in place of the original. I understand I am financially responsible for all charges whether or not covered by insurance.

SIGNATURE DATE






T H E


TOSC-004

patient information patient financial policy · home phone number day phone number cell phone...

Documents