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Microsoft word - new patient documentation.doc
Paymaun M. Lotfi, M.D. Richard L. Layfield, M.D.
Patients Last Name
If the patient is a Minor, Who is authorizing Treatment:/Accepting Financial Responsibility:
Primary Care doctor / Referring Physician Name:
(Medicare and HMO patients MUST list a Doctors name)
Other Referral Source:
Pharmacy Name and Phone Number:
Approx. date you first noticed this problem / Date of injury: (MM / DD / YY)
Worker’s Comp / Auto Insurance Company Name: W/C or Auto Insurance Address: W/C or Auto Ins Phone Number:
Patient Intake Form
Surgeon You Are Seeing Today: Reason For Your Appointment:
Past Medical History
Do you have a history of Bleeding Problems?
Medications (Please List Name, Dosage, and Frequency)
Have you taken any of the following in the past year:
Do you use Tobacco in any form: YES NO
Do you Drink alcohol: YES NO
Have you ever used IV drugs or other illegal substances: YES NO
Have you had any Physical Therapy: YES NO
Do you have a family history of arthritis, or Diseases of the muscles, bone, or nervous systems? YES NO
If yes, Please describe:
Do you have any family history of bleeding tendencies:
Do you have any family history of anesthesia problems:
Is there a family history of any other diseases you would
like the Doctor to know about: If Yes, Please Describe:
Are you currently working: YES NO
If no, when was your last day of work?
Is your regular type of work: HEAVY MEDIUM LIGHT SEDENTARY
Are you currently on any type of work restriction: YES NO
If Yes, What are the restrictions:
What regular exercise or sports do you participate in?
What are your hobbies?
Marital Status: Single Married Divorced/Separated Widowed
Children: YES NO
Review of Symptoms (Circle all that Apply)
Recent weight loss Recent Weight gain Fatigue Fever/Chills Night sweats
SKIN AND BREASTS
Rashes Sores Moles Lumps Excessive Bruising
EARS / NOSE / THROAT
Hearing Problems sinus Problems Gum/Tooth Disease Hoarseness
Blurred Vision Double Vision Blind Spots Glaucoma
Chronic Cough Wheezing Coughing Blood Emphysema Infections
Chest Pain High blood Pressure Leg Swelling Fainting Blood Clots
Nausea Heartburn Ulcers Swallowing Problems Abdominal Pain
Menopause Possibility of Pregnancy Incontinence Painful Urination
Blood in Urine Abnormal Vaginal Bleeding Vaginal/Pelvic Infections
Incontinence Painful Urination Blood In Urine
Trouble Starting Stream Prostate Problems Impotance
Fractures Muscle/Tendon Injuries Arthritis Joint Swelling Joint
Pain Childhood Deformity Childhood Braces Previous Infection
Dizziness Headache Slurred Speech Seizures Numbness/Tingling
Diabetes Thyroid Trouble Excessive Thirst
Depression Anxiety Excessive Stress Considered Suicide
Patient Signature:_________________________________________________________ Date: ____________________________
Financial , Payment , and General Office Policy
Insurance Patients: (This office participates with SOME insurance companies)
As a courtesy this office will verify your OUT OF
NETWORK benefits if we do not participate with your insurance, However it is ultimately your responsibility to understand what your
particular plan offers for NON participating providers. If we are a NON participating provider and your plan has no OUT OF
NETWORK benefits you will be responsible to pay any and all fees at the time of service. We will be happy to then provide you with
an itemized receipt so you may attempt reimbursement independently. Home and Auto insurance DOES NOT qualify as health
insurance. We will bill YOUR auto insurance however we WILL NOT bill third party auto insurance. Once your auto insurance
benefits are exhausted, it will be your responsibility to make sure we have additional health insurance on file for you to cover the cost
of your care. If no other health insurance is available, you will be responsible for any and all fees at the time of service. Co-payments
are due at the time of service and will be collected before you see the doctor. Medicaid Patients:
Please be aware that we are not a participating provider with Medicaid and there for CAN NOT bill them for ANY
services and/or you Medicare Coinsurance and you will be treated as a self pay patient. If Medicaid is secondary to Medicare, you will
be billed for your 20% Medicare Coinsurance. This is due in full upon receipt of our statement and NO payment plans can be arranged. Self Pay Patients:
All fees are due at the time of service. No personal checks will be accepted for these fees. They must be paid by
credit card, cashier’s check, cash, or money order. This office does not set up payment plans. Referrals:
If your insurance is an HMO and requires a referral it is your responsibility to bring that to your appointment at the time of
service. If you choose to come with out your referral you are risking your insurance not covering any services and you will be required
to pay for your visit in full at the time of service. Worker’s Compensation:
Nova Orthopedic and Spine Care and Village Physical Therapy require that you provide this office with
your workers compensation claims information and all other pertinent information prior to your visit for verification and authorization
from the Workers Compensation Insurance plan. Missed Appointments:
Please contact this office 24 hours in advance to reschedule or cancel an appointment. Failure to do so WILL
result in a $30.00 charge for a late cancellation or No Show. Phone Calls:
Nova Orthopedic and Spine Care and Village Physical Therapy staff may need to leave medical information regarding
your care on your answering machine if you are not available. Should you have any restrictions to this policy please
indicate:________________________________________________________________________________________________________________ Returned Check Fee:
Nova Orthopedic and Spine Care and Village Physical Therapy has an agreement with the bank to collect on all
returned checks after a check is returned for non-sufficient funds. You will be charged a $50 fee by the bank and no personal checks
will be accepted. Non-Payment:
If your account is turned over to a collection agency or attorney for non payment, you will additionally be responsible
for any and all additional fees permitted by law and a 33% collection fee will be added to your account. Assignment of Benefits:
By signing below you are authorizing Nova Orthopedic and Spine Care and Village Physical Therapy to
apply for benefits on your behalf for services rendered and request that payments be made directly to Nova Orthopedic and Spine Care
and Village Physical Therapy. I certify that the information I have reported regarding my health insurance coverage is correct and
current. I further authorize the release of any information, including but not limited to my medical information, for this or any other
related claim. I, the undersigned, hereby authorize the payment of medical and surgical benefits to be paid directly to Nova Orthopedic and
Spine Care and Village Physical Therapy. I fully understand that I am financially responsible for all charges whether or not they
are paid by the insurance. I authorize the physicians and staff of Nova Orthopedic and Spine Care and Village Physical Therapy to
release any information necessary to secure the payment of benefits.
I, the undersigned, have read all of the above information and disclaimers and agree that all medical and surgical charges incurred
by me or my dependants for services rendered by Nova Orthopedics and Spine Care and Village Physical Therapy.
I, the undersigned, acknowledge the receipt of the Statement of Privacy Practices, the Financial, Payment, and General Office
Policy statements and agree to the terms of these statements.
Signature of Patient/Parent/Responsible Party
Printed Name of Patient/Parent/Responsible Party
Authorization for the Disclosure of Private Health Information
I, __________________________________________, authorize Nova Orthopedic and Spine Care and Village Physical Therapy to release my private health information as necessary to physicians involved in my care, my insurance company, and others necessary for the purpose of Treatment, Payment, or Operations. I further authorize Nova Orthopedic and Spine Care and Village Physical Therapy to discuss my health or my account with the following individuals:
Signature of Patient/Parent/Responsible Party
Printed Name of Patient/Parent/Responsible Party
Notice of Privacy Practices
THIS NOTICE IS REQUIRED BY FEDERAL LAW AND DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices (.Notice.) describes the ways in which we may use and disclose your protected health information (PHI) and how you
can get access to this information. Protected health information. is information about you that is contained in your medical and billing records
maintained by this organization. It includes demographic information and information that relates to your present, past or future physical or mental
health and related healthcare services. Uses and Disclosures of Protected Health Information:
We may use and disclose your protected health information for purposes of healthcare
treatment, payment and healthcare operations as described below.
We may use and disclose your protected health information to provide, coordinate or manage your healthcare and any related services.
Examples of how we will disclose information for treatment may include sharing information about you with: referring physicians, your primary care
physician, a specialist, hospitals, ambulatory care centers, pharmacies or home health agencies.
Your protected health information will be used and disclosed as required, so that we can bill and receive payment for the treatment and
services you receive from us. Examples of how we will disclose information for payment include: contacting your health plan to confirm your coverage
or obtain precertification of a service, or we may provide information to any other healthcare provider who requests information necessary for them to
For Healthcare Operations:
We may use and disclose your protected health information in performing business activities that we call .healthcare
operations. This includes internal operations, such as for general administrative activities and to monitor the quality of care you receive at our facility.
Examples include: quality of care assessments, training of medical staff, assessing certain services that we may want to offer in the future, evaluating the
performance of our employees, licensing, or conducting or arranging other business activities. Other examples include: leaving messages on your
answering machine; leaving messages at your place of employment or sending out recall notices. We may use or disclose your protected health
information when making calls to remind you of your appointment. We will use a sign-in sheet at the receptionist’s desk where you will be asked to
sign your name and the name of the provider you are seeing. We will also call you by name when you are in our waiting room.
Other Uses and Disclosures We May Make Without Your Written Authorization:
Under the Health Insurance Portability and Accountability Act
(HIPAA) Privacy Regulations, we may use and disclose your protected health information in which you do not have to give authorization. These
situations include: those Required by Law, Public Health Risk Issues as required by Law, Communicable Diseases, Health Oversight Activities,
reporting Victims of Abuse, Neglect or Domestic Violence, Legal Proceedings, Law Enforcement, (this notice continues on the back of this page)
Coroners, Medical Examiners, Funeral Directors, Organ/Tissue Donation Organizations, Research; Criminal Activity; Military Activity and National
Security, Inmates/Law Enforcement Custody, and Workers Compensation.
Any Other Use or Disclosure of Your Protected Health Information Requires Your Written Authorization:
Will be made only with your consent,
authorization or opportunity to object, unless required by law.
Your Rights Regarding Your Protected Health Information:
You have the right to access your personal protected health information. Under federal
law, however, you may not inspect or copy the following records; psychotherapy notes, information compiled in reasonable anticipation of, or use in, a
civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health
information. You Have the Right to Request Restrictions:
You have the right to request a restriction on the way we use or disclose your protected health information
for treatment, payment or healthcare operations. You may make this request in writing, at any time. If we do agree to the restriction, we will honor that
restriction except in the event of an emergency and will only disclose the restricted information to the extent necessary for your emergency treatment.
You Have the Right to Request Confidential Communications:
You have the right to request that we communicate with you concerning your health
matters in a certain manner or at a certain location. For example, you can request that we contact you only at a certain phone number or a specific
address. We will accommodate your reasonable requests, but may deny the request if you are unable to provide us with appropriate methods of
You Have the Right to Request that We Amend your Protected Health Information:
If we deny your request, we will give you a written notice,
including the reasons for the denial. You can submit a written statement disagreeing with this denial. Your letter of disagreement will be attached to
your medical record.
You Have the Right to Request an Accounting of Certain Disclosures of Your Protected Health Information. You Have the Right to Obtain a Paper
Copy of This Notice
, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time by contacting our
office in writing or by phone.
You May Issue a Complaint
to our Privacy Officer (listed on the first page) or to the Secretary of Health and Human Services if you believe that your
privacy rights have been violated. We will not retaliate against you for filing a complaint.
We Reserve the Right to Change the Terms of This Notice of Privacy Practices
and to make the new provisions effective for all protected health
information we already have about you as well as any protected health information we create or receive in the future. If we make any changes, we will:
a. Post the revised Notice in our office(s), which will contain the new effective date; and b. Make copies of the revised Notice available to you upon
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