Patient In-Take Form Full Form

PATIENT INFORMATION

ACCIDENT INFORMATION - COMPLETE ONLY IF VISIT IS DUE TO AN ACCIDENT

IN CASE OF EMERGENCY

The above information is true to the best of my knowledge. I request that payment of authorized Medicare/other insurance benefits be made on my behalf to the Pennsylvania Pain & Spine Institute for any services furnished me by physician or supplier. I authorize the release of my medical information to Center for Medicare & Medicade Services and/or my insurance company and its agents; any information needed to determine these benefit/benefits payable for related services I am responsible for all charges, regardless of insurance status, as well as copayments and deductibles.

Checkboxes *

MORE INFORMATION

Previous Treatments: Have you had any of the following:

Epidural/s

Nerve block/s

Surgery/ies

Physical Therapy

Chiropractic

Social History

Family History

Past Medical History

Medications

Allergies

Consent to Treatment and Administrative Authorizations

1. Authorization for Treatment and Diagnostic Procedures

I voluntarily authorize, request and consent to outpatient care services, including procedures, examinations, and medical treatment as ordered by my physicians, his/her assistants, or other health care provides. I understand that, except in emergency situations, this consent does not include surgical procedures or other procedures or treatment that may require separate consent. I acknowledge that the practice of medicine is not an exact science and that no guarantees have been made as to the results of any procedures, treatments or examinations.

2. Release of Information (Including Medical Record Information)

I authorize the Pennsylvania Pain & Spine Institute to furnish health, demographic, and other information from my medical records to my insurance company, third-party payers, case utilization, and managed care review organizations, which may be necessary in order for Pennsylvania Pain & Spine Institute to receive payment or obtain authorization for my care. I further authorize health, demographic, and other information from my medical record to be released to any health care provider or institution providing health care to me. Consent is also given for release of information to Pennsylvania Pain & Spine Institute by any insurer and all other agencies, institutions, or from whom I have received medical services. This authorization does not apply to information specifically protected by state or federal laws or regulations.

3. Assignment of Insurance Benefits to Pennsylvania Pain & Spine Institute

I authorize payment of health care benefits directly to Pennsylvania Pain & Spine institute. In making this assignment, I understand and agree that I may be financially responsible to Pennsylvania Pain & Spine Institute for charges not pain under my insurance policy(ies). I permit a copy of this authorization to be used in place of the original.

I authorize payment of authorized Medicare or other payor benefits to be made to me or on my behalf, to the physician or supplier for any services provided to me by the authorized physician or supplier. I authorize any holder of medical information about me to release to the Center for Medicare and Medicade Services and its agents and information needed to determine these benefits or the benefits payable for related services.

I hereby certify that I have read and fully understand the above consent. I have sufficient opportunity to ask whatever questions I might have and they have been answered to my satisfaction. I voluntarily and freely consent to the above and accept its term.

A Word About Missed Appointments

Thank you for chosing Pennsylvania Pain & Spine Institute for your pain management care. To enable us to provide you with the best possible care please read the following carefully. It is important for you to follow these instructions to get the most from your upcoming appointment.
If you are unable to keep your appointment, please notify our office at least 24 hours prior to your appointment for rescheduling. This improves appointment availability for both you and our other patients. If you no-show for an appointment or cancel less than 24 hours before your appointment, you will be charged $25.00. If you miss two (2) appointments or are late (more than 20 minutes) two (2) times, we will take this as an indication that you are no longer interested in being a patient of Pennsylvania Pain & Spine Institute. We will then discharge you as a patient.
We recognize that emergencies occur, and you may be unable to cancel an appointment in rare circumstances. However, no shows and cancelations will force us to enforce our policy.
Thank you in advance for your cooperation.
Sincerely,
The Staff at Pennsylvania Pain & Spine Institute

Notice of HIPAA Acknowledgement

I have acknowledged that I have received the attached copy of the Pennsylvania Pain & Spine Institute Notice of Privacy Practices.

DOWNLOAD PENNSYLVANIA PAIN & SPINE INSTITUTES NOTICE OF PRIVACY POLICY

STATEMENT OF PATIENT FINANCIAL RESPONSIBILITY

This is a statement of our financial policy. You understand that you are obligated to ensure that our fees are paid in full. We will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill.
You agree that you will pay any deductible and co-payment or co-insurance as determined by your insurance plan. Those payments will be due at the time of service. Many insurance companies have additional requirements or stipulations that may affect your coverage. You are responsible for any amounts not covered or payable by your insurance. If your insurance denies any part of your claim, you agree to be responsible to pay the full balance.

ACKNOWLEDGEMENT
I have read and understand the financial policy described above. I agree to pay, promptly and in full, any amounts due to the provider, including co-payments, deductibles, and amounts due for non-covered or services that are not payable by my insurance.

(Use if patient is a minor or otherwise has an authorized representative)

Medical Information (HIPAA) Release Form

Release of Information

I authorize the release of information including the diagnosis, records, examination rendered to me and claims information. This information may be released to:

Messages

Please call my:

If unable to reach me:

REVIEW OF SYSTEMS

For new patients, established patients who may be having a new problem, or our patients who we haven’t seen for a while, we need to update our records as to your general medical health. In each area, if you are not having any difficulties, please select “No Problems”. If you are experiencing any of the symptoms listing, PLEASE CHECK ALL BOXES THAT APPLY, or explain any that may not be listed. If you have any questions about this, please ask one of the technicians, or your doctor.

Const. (Health in General)

No Problems
Lack of energy
unexplained weight gain or weight loss
loss of appetite
fever
night sweats
pain in jaws when eating
scalp tenderness
prior diagnosis of cancer

Ears, Nose, Mouth & Throat

No Problems
Difficulty with hearing
sinus problems
runny nose
post-nasal drip
ringing in ears
mouth sores
loose teeth
ear pain
nosebleeds
sore throat
facial pain or numbness

C-V (Heart & Blood Vessels)

No Problems
Irregular heartbeat
racing heart
chest pains
swelling of feet or legs
pain in legs with walking

Resp. (Lungs & Breathing)

No Problems
Shortness of breath
night sweats
prolonged cough
wheezing
sputum production
prior tuberculosis
pleurisy
oxygen at home
coughing up blood
abnormal chest x-ray

GI (Stomach & Intestines)

No Problems
Heartburn
constipation
intolerance to certain foods
diarrhea
abdominal pain
difficulty swallowing
nausea
vomiting
blood in stools
unexplained change in bowel habits
incontinence

GU (Kidney & Bladder)

No Problems
Painful urination
frequent urination
urgency
prostate problems
bladder problems
impotence

MS (Muscles, Bones, Joints)

No Problems
Joint pain
aching muscles
shoulder pain
swelling of joints
joint deformities
back pain

lnteg. (Skin, Hair & Breast)

No Problems
Persistent rash
itching
new skin lesion
change in existing skin lesion
hair loss or increase
breast changes

Neurologic (Brain & Nerves)

No Problems
Frequent headaches
double vision
weakness
change in sensation
problems with walking or balance
dizziness
tremor
loss of consciousness
uncontrolled motions
episodes of visual loss

Psychiatric (Mood & Thinking)

No Problems
Insomnia
irritability
depression
anxiety
recurrent bad thoughts
mood swings
hallucinations
compulsions

Endocrinologic (Glands)

No Problems
Intolerance to heat or cold
menstrual irregularities
frequent hunger/urination/thirst
changes in sex drive

Hematologic (Blood/Lymph)

No Problems
Easy bleeding
easy bruising
anemia
abnormal blood tests
leukemia
unexplained swollen areas

Allergic/Immunologic

No Problems
Seasonal allergies
hay fever symptoms
itching
frequent infections
exposure to HIV
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