Sex: DMale Female. Last name: Insurance 1D#

Full text

(1)

ORTHOPEDIC CARE AND SURGERY

Patient Demographic Information (Please print and fill out completely) Acct #

DOB: Sex: DMale • Female

pg 1 of 8

Name: Address:

Home Phone:', Work Phone: Patient's Social Security #:

Primary Care Physician: Referring Doctor: First name: Pharmacy Name/Address:

Cell Phone:

Last name:

Phone

Race: • Caucasian • Afiican American • Native American • Asian • Hispanic Ethnicity: • Hispanic/Latino •Non-Hispanic • Declined Language Insurance Information

Primaiy Insurance Insurance ID #. Group # ; Effective date of insurance: Policy Holder Name(skip i f same as patient):_

Secondai7 Insurance:

Policy Holder Name (skip i f same as patient):^ Effective date of insurance:

DOB

Insurance 1D# Groupr

DOB

Employer:_ Address: Phone:

**Is this visit related to an automobile or work accident? D N o • Yes I f yes please indicate • Auto D W o r k I f yes please complete No fault/Workers Comp form attached.

Responsible Party • ( i f same as patient, check and skip to next section) Name Date of Birth Address SSN: (Street) (City) Home Phone (State) Cell Phone (Zip) Work Phone

Spouse/Significant Other Name_ Date of Birth

Emergency Contact/HIPAA Contact_ Phone

Address Relationship to Patient

The information on all forms has been completed accurately to the best of my knowledge. I understand that it is my responsibility to notify the doctor's office of any changes in my infomiation. I also understand that this information will also be used for billing purposes and that I authorize the WNY KNEE AND ORTHOPEDIC SURGERY, PC to bill my insurance.

Printed name of patient or guardian: (if patient under 18 years of age)

(2)

WNY K N E E AND O R T H O P E D I C S U R G E R Y , P C D O C T O R P O L I C Y - P A T I E N T C O P Y

Acct#

pg2 of 8

*YOU W I L L NOT BE SEEN WITHOUT A N UPDATED REFERRAL IF ONE IS REQUIRED BY YOUR INSURANCE COMPANY. IF WE DO NOT HAVE A REFERRAL, YOUR APPOINTMENT M A Y BE RESCHEDULED. IT IS YOUR RESPONSIBILITY TO CALL YOUR MEDICAL DOCTOR TO O B T A I N A REFERRAL.

* C O - P A Y M E N T S AND D E D U C T I B L E S A R E D U E A T T H E T I M E O F A P P O I N T M E N T .

W E A C C E P T C A S H , C H E C K , O R C H A R G E ( M A S T E R C A R D , VISA, AND D I S C O V E R C A R D )

*IF Y O U ARRIVE MORE T H A N 15 MINUTES LATE, YOUR APPOINTMENT M A Y BE RESCHEDULED TO THE NEXT A V A I L A B L E APPOINTMENT.

*IF Y O U NEED TO CANCEL YOUR APPOINTMENT, WE REQUIRE A 24-HOUR NOTICE OR Y O U M A Y BE CHARGED A $50.00 NO SHOW FEE. THERE IS A $250.00 NO SHOW FEE FOR SURGERY.

*IF Y O U FAIL TO SHOW UP FOR 2 SCHEDULED OFFICE APPOINTMENTS WITHOUT CANCELLING, WE W I L L BE UNABLE TO CONTINUE YOUR CARE.

*ALL MEDICATION REFILLS CALLED I N AFTER 4PM ON THURSDAYS W I L L BE FILLED THE FOLLOWING MONDAY. PLEASE PLAN ACCORDINGLY.

*IF YOU ARE WAITING FOR A RETURN CALL FROM A PHYSICIAN, THIS W I L L BE HANDLED AS QUICKLY AS POSSIBLE. NON-EMERGENT CALLS W I L L BE RETURNED AFTER OFFICE HOURS I N MOST CASES. ROUTINE CALLS SHOULD BE MADE DURING BUSINESS HOURS.

*OUR OFFICE IS OPEN M O N D A Y THRU FRIDAY SAM TO 4PM. CALLS M A D E AFTER HOURS OR ON WEEKENDS ARE FOR EMERGENCIES ONLY. IF Y O U HAVE A CALL BLOCK ON YOUR PHONE, PLEASE TURN IT OFF SO OUR

PROVIDERS ARE ABLE TO RETURN YOUR CALL.

ALTHOUGH UNUSUAL WE APOLOGIZE FOR OUR PROLONGED W A I T TIMES, BUT WE OFTEN SEE A LARGE NUMBER OF UNSCHEDULED PATIENTS DUE TO EMERGENCIES.

PATIENT FORMS

THERE IS A $10.00 FEE FOR FORMS TO BE FILLED OUT. THE PAPERWORK W I L L NOT BE COMPLETED UNTIL THE FEE IS RECEIVED. PLEASE DO NOT ASK THE PHYSICIAN TO FILL FORMS OUT DURING OFFICE VISITS. FORMS ARE DONE ON A FIRST COME FIRST SERVED BASIS A N D WE REQUIRE 7 DAYS TO PROCESS PAPERWORK.

FINANCIAL POLICY

(3)

W N Y KNEE A N D ORTHOPEDIC SURGERY

pg3 of 8

Keith Stube, M D Jeffrey Rassman, RPA-C Allison Morganti, RPA-C

Michael Parentis, M D Matthew Mazurczak, RPA-C Breanne Finucane, RPA-C 180 Park Club Lane, Suite 225, Williamsville, N Y

3712 Southwestern Boulevard, Orchard Park, N Y

14221 716-839-5858 14127 716-508-8252

HIPAA-Your Health Infomiation is Protected by Federal Law What Infomiation is Protected?

-Infomiation your doctors and other health care providers put in your medical record. -Conversations your doctor has about your care or treatment with others.

-Information about you in your health insurers computer system. -Billing information about you from your clinic/healthcare provider.

-You decide i f you want to give permission before your health information may be shared. - I f you believe your health information isn't being protected, you can:

File a complaint with your health care provider or health insurer File a complaint with the US Government

-You can ask your provider or health insurer questions about your rights.

Providers and health insurers are required to follow this law and must keep your information private by: -Teaching people who work for them how your information may and may not be shared.

-Taking appropriate and reasonable steps to keep your health information secure. To make sure your information is protected in a way that does not interfere with your healthcare, you information can be used and shared:

-For your treatment and care coordination. -To pay doctors and hospitals for your healthcare.

-With family, friends or others you identify who are involved with your healthcare. For more information:

(4)

Name: DOB: Acct# pg4 of 8 W N Y KNEE A N D ORTHOPEDIC SURGERY, PC

ORTHOPAEDIC CARE & SURGERY

Acknowledgement of Receipt of Notice of Privacy Practices

By my signature below, I hereby acknowledge receipt of the Notice of Privacy Practices:

Signature: Date:

Medical Information Release Form (HIPAA Release Form)

Name: Date of Birth:

/

/

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:

• Spouse • Child(ren) • Other

• Information is not to be released to anyone.

This Release of Information will remain in effect until tenninated by me in writing.

.Signed: Date: /

/

M I C H A E L A. PARENTIS, M . D . Breanne Finucane, RPA-C Matthew Mazurczak, RPA-C

K E I T H C. STUBE, M.D. Allison Morganti, RPA-C Jeffrey Rassman, RPA-C NORTHTOWNS

(5)

Acct#

pg5 of8 WNY KNEE A N D ORTHOPEDIC SURGERY, PC

ORTHOPAEDIC CARE & SURGERY

FINANCIAL POLICY & INSURANCE WAIVER

We are committed to providing you with the best care, and in return, expect full and prompt payment for our services. Your clear understanding of the following policies and your responsibility is important to our professional relationship:

- Copayments are due at the time of service.

- Our office requires a 24 hour notice when cancelling an appointment, otherwise a $50.00 fee may be charged to your - We participate in most insurance plans. However, insurance is primarily a contract between you and your carrier. We must _ comply with the rules and regulations of your policy. Therefore, any balance due, per your carriers notification, is your

responsibility. Please be aware of your covered benefits.

I UNDERSTAND THAT W N Y KNEE A N D ORTHOPEDIC SURGERY, PC M A Y NOT ACCEPT M Y INSURANCE A N D THAT IT IS M Y RESPONSIBILITY TO VERIFY W I T H M Y HEALTH INSURANCE WHETHER OR NOT THE KNEE CENTER OF WNY IS A PARTICIPATING PROVIDER. 1 HEREBY AGREE TO PAY THE FULL A M O U N T OF M Y OFFICE VISIT/SURGERY AT THE TIME OF SERVICE IF THEY ARE A NON-PARTICIPATING PROVIDER. FOR YOUR

CONVENIENCE, WE ACCEPT MASTER CARD, VISA A N D DISCOVER CARD FOR PAYMENT OF A L L CHARGES. RELEASE OF INFORMATION A N D ASSIGNMENT OF BENEFITS

I have reviewed & understand the above financial policy & agree with the stated terms. I also authorize direct payment of medical benefits to the W N Y KNEE A N D ORTHOPEDIC SURGERY, PC & the release of medical information necessary for treatment, payment & healthcare operations.

SIGNED: DATED:

It has been explained to me that the W N Y KNEE A N D ORTHOPEDIC SURGERY, PC may not participate with my health .insurance plan. I understand that it is my responsibility to verify with my health insurance whether or not WNY KNEE A N D

ORTHOPEDIC SURGERY, PC is a participating provider. I hereby agree to pay the full amount of my office visit/surgery at the time of service i f they are a non-participating provider. I understand that any balance that has not be satisfied at the time of service will be due immediately upon receipt of my first statement. I f payment is not received or other arrangements are not made, further collection activity will commence.

account.

PATIENT INSURANCE WAIVER

SIGNED: DATED:

M I C H A E L A. P A R E N T I S , M.D, Breanne Finucane, RPA-C Matthew Mazurczak, RPA-C

K E I T H C . S T U B E , M.D. Allison Morganti, RPA-C Jeffrey Rassman, RPA-C NORTHTOWNS

(6)

WNY KNEE A N D ORTHOPEDIC SURGERY, PC M E D I C A L HISTORY FORM pg 6 of 8 Name:

Age:

Date of Birth: Date:

Height^ Weight Acct#

Primary Care Physician Main Complaint:

Referred by

• Left • Right

Wound care Physician (if applicable): Rheumatologist ( i f applicable):

Infectious Disease doctor (if applicable): Location of Pain:

Severity DO • 1 • 2 0 3 0 4 D5 D6 • ? 0 8 0 9 D I O

(least) What causes the pain? Pain Duration CuiTent Problem • No Pain • Started Today • Started Yesterday • For a While Days Wks Mos_ Pain Timing • Continuous • Intemiittent • Occasional • Worse at night • Worse w/activity (most) Yrs Pain Quality • No Pain • Burning • Sharp • Sore • Stabbing

Aggravates your Pain • Activity • Bending • Moving Pain Severity • 1 (none) • 2 • 3 • 4 • 5 (moderate) • 6 • 7 • 8 • 9 • 10(severe)

Alleviates your Pain • Anti-inflammatoi7 • Rest

• Heat • Ice u worse w/acuvuy

Associated symptoms: • Catching • G i v i n g Out • Popping • Spasms •Stiffness List any allergies you have to drugs, food or other items: • no known drug allergy Past Medical Problems:

Past Surgical History Operations Performed REVIEW OF SYSTEMS Gastrointestinal (GI) • Abdominal Pain • Diarrhea • Nausea • Vomiting • Reflux Neurologic • Blackouts • Fainting • Headaches • Tingling Year Hospital Cardiovascular • Chest Pain • Fainting • Leg Swelling • Ankle Swelling • Exercise Intolerance Respiratory • Difficulty Breathing • Cough • Congestion • Wheezing Doctor Musculosketal • Muscle Cramps • Stiffness • Back Pain • Joint Pain • Joint Swelling Blood/Lymph • Easy Bleeding • Excess Bleeding • Enlarged Lymph • Easy Bruising

Work Related? DYes D N o Lawsuit? QYes D N o Attorney Name: Occupation: List prior Job i f retired

• Married • Widowed • Divorced # of children Marital Status • Single

Do you smoke? DYes D N o Do you drink alcohol • Yes

Packs per day_ • No #Drinks per day

(7)

WNY K N E E AND O R T H O P E D I C S U R G E R Y , PC M E D I C A T I O N L I S T

pg7of8

Medication List

Name: Acct #

Are you currently taking any medications? If yes, please list below:

• Yes • No

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often

Name , Dosage How Often

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often

(8)

W N Y K N E E AND O R T H O P E D I C S U R G E R Y , P C FOOT & ANKLE .HIPS .KNEES .SHOULDERS SPECIALIZING IN SPORTS INJURIES & MEDICINE

Pg8of8

K E I T H C. S T U B E , M.D. M I C H A E L A. P A R E N T I S , M.D.

JEFFREY RASSMAN, RPA-C • ALLISON MORGANTI, RPA-C MATTHEW MAZURCZAK, RPA-C .BREANNE FINUCANE, RPA-C

M E M O

To: All Patients

From: Providers of WNY Knee and Orthopedic Surgery, PC Re: Estimates on Deductibles and Procedures

Due to recent changes in government and insurance policies, the providers of WNY Knee and Orthopedic Surgery, PC are working to be proactive and give patients estimates for upcoming procedures and visits when they have deductibles and changes in

co-payments.

When procedures are considered elective, we will be asking for payment up front. Our staff is working diligently to get you this information, but as you are aware, deductibles update on a daily basis. Our staff will inform you prior to your surgery of the cost related to your procedure. VISCO injections and Durable Medical Equipment are also services that we render to our patients. These services can be costly when you still need to meet your deductible and/or coinsurance. Should you decide to move forward and receive the service, our policy is to collect your portion at the time of the visit. Our goal is to give you this information prior to the service being rendered.

I f you have any questions regarding your deductible or coinsurance, please call our billing department at 839-5858 option 9 and a billing representative will help you.

'180 PARK CLUB LANE, SUITE 225 3712 SOUTHWESTERN B L V D . WILLIAMSVILLE, N Y 14221 ORCHARD PARK, N Y 14127

(P) 718-839-5858 (F) 716-839-5925 (P) 716-508-8252

Figure

Updating...

References

Updating...

Related subjects :