PATIENT NAME:
(Last) ______________________________ (First) ______________________________ (Middle) ______
□
Female
□
Male
Birth Date: __________ Age: _________ Social Security No: ________________
□
Single
□
Married
□
Widowed
□
Divorced
Mailing Address: _______________________________________________________________________
(City) ____________________ (State) __________ (Zip) __________
Phone: Home: _______________ Cell: _______________ Work: _______________ ok to leave a message
□
Yes
□
No
Preferred Phone: _______________ ok to leave a message
□
Yes
□
No Email: ______________________________
***By signing this document, I am giving Tri City Orthopaedic Clinic permission to contact me on all phone numbers listed.
Ethnicity:
□
Caucasian
□
Hispanic/Latino
□
Asian
□
American Indian/Alaskan Native
□
Black/African American
□
Native Hawaiian/Other Pacific Islander
□
Decline
Language:
□
English
□
Spanish
□
Russian
□
Other
Interpreter Service: _______________________
□
Employed
□
Unemployed
□
Full Time Student
□
Retired
□
Disabled
Employer: __________________________________________________ Phone: ____________________
Referring Source (i.e. Doctor, TV, Newspaper, Friend): ______________________________
Reason For Visit (List Body Part):
□
Left____________
□
Right____________
Person Responsible For Payment: (if patient is a minor under 18):
(Last) ______________________________ (First) ______________________________ (Middle) ______
□
Female
□
Male
Birth Date: __________ Age: _________ Social Security No: ________________
Mailing Address: _______________________________________________________________________
(City) ____________________ (State) __________ (Zip) __________
Phone: Home: _______________ Cell: _______________ Work: _______________
Employer: __________________________________________________
IS THIS PROBLEM WORK RELATED?
□
Yes
□
No Employer at the time of injury: __________________
Injury Date: _______________Claim Number: _______________ Claim Manager: ___________________
Last date worked: ___________________
Industrial Insurance Carrier: ______________________________________________________________
Insurance Carrier Address: _______________________________________________________________
(City) ____________________ (State) __________ (Zip) __________ Phone: ________________
Is the Claim Currently Open:
□
Yes
□
No
If Not, When Did the Claim Close? _______________
IS THIS PROBLEM THE RESULT OF A MOTOR VEHICLE ACCIDENT?
□
Yes
□
No
Date of Accident: _______________
State Accident Occurred: _______________
Claim Number: _________________ Claim Manager: ______________________ Phone: _____________
MVA Insurance: ________________________________________________________________________
MVA Insurance Address: _________________________________________________________________
(City) ____________________ (State) __________ (Zip) __________ Phone: ____________________
Created: 4/5/2012 Edited: 12/5/13
Primary Medical Insurance:__________________________ Effective Date: ____________
Subscriber ID #:_________________________
Group #:_______________ Copay:______
Subscriber Name: _________________________________________________
Subscriber Birth Date: ______________ Social Security No: ________________
Subscriber Address: Mailing Address: _______________________________________________________
(City) ____________________ (State) __________(Zip) __________
Phone: Home: _______________ Cell: _______________ Work: _______________
Subscriber Employer: ____________________________________________
Secondary Medical Insurance: __________________________ Effective Date: ____________
Subscriber ID #:_______________________
Group #:_______________ Copay:______
Subscriber Name: _________________________________________________
Subscriber Birth Date: __________ Social Security No: ________________
Subscriber Address: Mailing Address: _______________________________________________________
(City) ____________________ (State) __________ (Zip) __________
Phone: Home: _______________ Cell: _______________ Work: _______________
Subscriber Employer: ____________________________________________
Tertiary Medical Insurance: __________________________ Effective Date: ____________
Subscriber ID #:__________________________
Group #:_______________ Copay:______
Subscriber Name: _________________________________________________
Subscriber Birth Date: __________ Social Security No: ________________
Subscriber Address: Mailing Address: _______________________________________________________
(City) ____________________ (State) __________(Zip) __________
Phone: Home: _______________ Cell: _______________ Work: _______________
Subscriber Employer: ____________________________________________
Emergency Contact:
(Last) ______________________________ (First) ______________________________ (Middle) ______
Phone: Home: _______________ Cell: _______________ Work: _______________
Relationship to Patient: __________________________ Birth Date: __________
I have completed the above information to the best of my knowledge. I request that payment of authorized benefits be made to me or on my behalf to Tri City Orthopaedic Clinic for any services furnished to me. I authorize Tri City Orthopaedic Clinic to release any medical information which may be requested to determine benefits through my above named insurance carrier. I understand that if any insurance does not pay in full for services provided by Tri City Orthopaedic Clinic, I assume liability for the unpaid portion. This agreement shall be governed and enforced in accordance with the laws of the State of Washington.
X____________________________________________________________________________________
Revised: 03/24/2014 Created: 03/19/2013
6703 W Rio Grande Ave. 821 Swift Blvd. 965 Goethals Dr. Kennewick, WA. 99336 Richland, WA. 99352 Richland, WA. 99352 Ph: (509) 460-5588 Ph: (509) 460-5588 Ph: (509) 460-5588 Fax: (509) 783-5438 Fax: (509) 946-7253 Fax: (509) 943-9521
Office Policies for Tri-City Orthopaedic Clinic
Patient Information:
You are required to provide photo identification at each visit along with any current insurance information. Please notify the receptionist when you have any changes to the following: Address, phone (work, cell or home), insurance.
Co-pays/Deductibles/Co-insurances:
If your insurance requires any of the above, you will be asked to pay this at the time of service. For your convenience we accept cash, check, debit/credit cards (Visa, MasterCard, Discover and American Express). If you are unable to pay these at time of service you agree to a $20 fee to be added to your bill.
Prior Balances:
Prior balances must be paid within 30 days unless a signed payment plan has been executed.
Self Pay:
We ask that payment be made in full at the time of service unless prior arrangements have been made with the Patient Account Representative. We accept cash, debit and/or credit cards (Visa, MasterCard, Discover and American Express). If we are an out of network provider with your insurance company and you do not have out of network benefits, then you will be considered a cash pay patient and agree to the cash pay policy above.
Reminder Calls:
As a courtesy you will receive an automated reminder call for your scheduled appointment. We ask if you are unable to make this appointment to notify us as soon as possible. Ultimately it is your responsibility to remember your appointment time and date.
Cancelled or Missed Appointments:
We will do everything possible to make sure that your appointment is on schedule. Patients arriving more than 15 minutes late may not be seen. New patients who do not arrive early enough to complete paperwork before their appointment may need to be rescheduled.
No Shows:
If you are unable to show up for a scheduled appointment we require a phone call 24 hours (not including weekends) in advance. If an emergency arises and you need to call and cancel an appointment with less than 24 hours notice, please let the receptionist know the reason for your cancellation. If this is not done the cancellation may be designated as a “No Show”. After three (3) “No Show” appointments, TCO may discharge you from the clinic.
Insurance:
Many people are under the impression that if they have insurance, it is the insurance company that owes TCO for your services. This is NOT the case. TCO bills your insurance as a courtesy. The insurance contract is between you and the insurance company. If your insurance does not pay TCO please contact the billing department to make payment arrangements.
Revised: 03/24/2014 Created: 03/19/2013
Workman’s Compensations/Motor Vehicle Accidents:
All information has to be provided prior to scheduling the appointment in order to verify claim is open and allowed or that Personal Injury Protection is not exhausted or your appointment may be rescheduled. If no private insurance is available and we areunable to verify an open claim, there is a mandatory $150.00 deposit required at time of service in the form of cash/check/credit/debit/money order. Once we verify a claim is open and allowed, we will refund any money owing on the claim (refer to Refund policy).
Prescription Refills:
We require 24-48 hours notice on all refills. Refill requests accepted during office hours only, as posted, or online via our website. Any prescription refill requests need to go thru your pharmacy. Request a fax to be sent to our office for the refill. Due to our surgery schedules, the physicians are not always available to sign medication requests.
Forms and/or Paperwork Fee:
There is a $15.00 fee for the completion of a form or paperwork. We require 7-10 working business days to complete both.
Bankruptcy:
If you have previously declared bankruptcy within our clinic, you will be required to sign a Bankruptcy Contract. There is a $75.00 deposit prior to each visit in the form of cash/credit/debit/money order. After each visit, your patient responsibility will be calculated and the deposit will be applied, any additional amount owing will be collected at this time. Any refund will be processed at this time. As a courtesy we will bill your insurance.
Collection:
If you have previously been sent to collections, you will be required to sign a Collection Contract. There is a $75.00 deposit prior to each visit in the form of cash/credit/debit/money order. After each visit, your patient responsibility will be calculated and the deposit will be applied, any additional amount owing will be collected at this time. Any refund will be processed at this time. As a courtesy we will bill your insurance.
Refund:
If you feel you have a credit on your account, please contact the Billing Department. If all your care is completed and all services have been paid a refund will be issued within two (2) weeks after an account audit has been conducted. Even if no request has been made account audits are regularly conducted and any refund owing will be issued once audit is completed.
I have read and agree to the above. Further, I agree that if I fail to abide by these
policies I may be discharged from the clinic.
Patient Name (Print) Date of Birth
Revised: 8/7/13
Created: 4/5/12
6703 W Rio Grande Ave 821 Swift Blvd 965 Goethals Dr Kennewick, WA 99336 Richland, WA 99352 Richland, WA 99352 Ph: (509) 460-5588 Ph: (509) 460-5588 Ph: (509) 460-5588 Fax: (509) 783-5438 Fax: (509) 946-7253 Fax: (509) 943-9521
CONSENT FOR USE AND DISCLOSURE OF PRIVATE HEALTH INFORMATION FOR TREATMENT, PAYMENT AND
HEALTH CARE OPERATIONS
Patient Name: ________________________________ Date of Birth ______________________
SSN: ______________________
Previous Name (if any) ________________________
My health information is a private matter. Tri-City Orthopaedic Clinic, PSC has a form that can tell me how his
clinic handles my health care information. This form is entitled “Notice of Privacy Practices”. If I ask, Tri-City
Orthopaedic Clinic, PSC will provide me with the most current “Notice” before I sign this consent. I
understand that the clinic may update this “Notice” at any time and that if I request it, I will receive a current
copy of the “Notice”.
I agree that Tri-City Orthopaedic Clinic, PSC may use and disclose my health information to help treat me, for
insurance and billing related to my physician visits and for other health care operations such as appointment
reminders, calling with results of laboratory tests and performing health quality improvements in the practice.
I also understand that the law sometimes requires the release of health care information
without
my approval
such as in cases of child abuse or neglect.
I may ask Tri-City Orthopaedic Clinic, PSC to further limit the use or disclosure of my health information and
that I must do this in writing. The clinic is not required to agree to my request but will usually attempt to meet
my restrictions.
I may cancel this consent at any time, by doing one of the following:
Signing and dating a revocation form. I may get this form from the clinic;
Writing, signing and dating a letter to Tri-City Orthopaedic Clinic, PSC which says that I cancel
my consent to authorize the use and disclosure of my health care information for treatment,
payment and health care operations.
If I cancel this consent:
It will be effective except for actions already taken based upon the Consent: and
Tri-City Orthopaedic Clinic, PSC will not have to provide any more health care services to me.
I have been given the chance to read a current copy of Tri-City Orthopaedic Clinic, PSC’s “Notice of Privacy
Practices”. I agree to allow Tri-City Orthopaedic Clinic, PSC to use and disclose my health information to carry
out treatment, payment and health care operations.
___________________________________________
_______________________
Revised: 8/7/13
Created: 4/5/12
Consent To Inform – Your Right to Privacy
** PLEASE PRINT**
PATIENT’S NAME: _________________________________________________________________
We respect your right to privacy regarding medical information. Without additional written consent, may
share information with your spouse?
If yes, their name: ____________________________________________________________________
We understand you may have concerned relatives. Please list the names of adults, children, other family
members and/or contact persons with whom we may share information, without additional written consent,
and their relationship to the patient:
Check if N/A (not applicable): ____________
Name: _________________________________
Relationship to Patient: _________________________
Name: _________________________________
Relationship to Patient: _________________________
Name: _________________________________
Relationship to Patient: _________________________
Name: _________________________________
Relationship to Patient: _________________________
Name: _________________________________
Relationship to Patient: _________________________
** If there are any changes to be made on this form it is the patient’s responsibility to let us know at each
occurrence.
____________________________________________________________________________________
Signature of patient or patient’s authorized representative
Date:
____________________________________________________________________________________
Relationship or status if signed by anyone other than patient (parent, legal guardian, etc.)
Dr Shoham New Patient Intake Paperwork
Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best care possible.
NAME: ______________________________________ DOB_______________ TODAY’S DATE_________ Weight:_______________ Height: _______________
Pain Description______ ____________________________________________________
Please use the pain scale described below to rate your pain for the questions below: 0- Pain Free
1- Very minor annoyance, occasional minor twinges 2- Minor annoyance, occasional strong twinges 3- Annoying enough to be distracting
4- Can be ignored if you are really involved in your work/task, but still distracting 5- Cannot be ignored for more than 30 minutes
6- Cannot be ignored for any length of time, but you can still go to work and participate in social activities 7- Makes it difficult to concentrate, interferes with sleep, but you can still function with effort
8- Physical activity is severely limited/ you can read and talk with effort. Nausea and dizziness caused by pain. 9- Unable to speak, crying out or moaning uncontrollably, near delirium
10- Unconscious. Pain makes you pass out
_____What number on the pain scale (0-10) best describes your pain right now?
_____What number on the pain scale (0-10) best describes your worst pain?
_____What number on the pain scale (0-10) best describes your least pain?
_____What number on the pain scale (0-10) best describes your average pain over the last month?
Use this diagram to indicate the location and type of you pain. Mark the drawing with the following letters that best describe your symptoms:
“B” = burning
“D” = deep
“DU” = dull
“E” = electric
“N” = numbness
“SP” = sharp
“SH” = shooting
“S” = stabbing
“B” = burning
“P” = pins and needles
“A” = aching
“T” = “Throbbing”
Where is your worst area of pain located? _____________________________________________ Does this pain radiate? If so, where? :_________________________________________________ Please list any additional areas of pain: ________________________________________________ What makes the pain better? ________________________________________________________ What makes the pain worse? ________________________________________________________
MARK ALL OF THE FOLLOWING ACTIVITIES THAT ARE ADVERSELY/NEGATIVELY AFFECTED BY YOUR PAIN:
□ Enjoyment of life □ Normal Work □ General Activity □ Recreational Activities
□ Walking □ Mood □Relationships with People
Onset of Symptoms_________ _________________________________________________
Approximately when did this pain begin? ___________________________________________________ What caused your current pain episode? ___________________________________________________
Is your pain the result of a Motor Vehicle Accident or Personal Injury (legal term used to describe an injury sustained to
you by the negligence of another) □ Yes □ No
How did your current pain episode begin? □ Gradually □ Suddenly
Since you pain began, how has it changed? □ Decreased □ Increased □Stayed the same Pain Description______ ____________________________________________________
Check all of the following that describe your pain:
□ Aching □ Hot/Burning □ Stabbing/Sharp □ Cramping
□ Shock-like □ Tingling/ Pins and Needles
What word best describes the frequency of your pain? □ Constant □ Intermittent
When is your pain at its worst? □ Morning □ During the day □Evenings □ Middle of the Night
In the past three months have you developed ANY NEW:
□ Balance Problems □ Bladder Incontinence □ Bowel Incontinence □ Chills □ Difficulty Walking □ Fevers □ Nausea □ Vomiting
□ Numbness/Tingling – Where? ___________________ □ Weakness – Where? ____________________ □ I HAVE NOT RECENTLY DEVELOPED ANY OF THE ABOVE CONDITIOINS.
Diagnostic Tests and Imaging______________________________________________________
Mark all of the following tests you have had that are related to you current pain complaints:
□ MRI of the __________________________________ Date: ____________ Facility: _______________ □ X-Ray of the ________________________________ Date: ____________ Facility: _______________ □ CT scan of the _______________________________ Date: ____________ Facility: _______________ □EMG/NCV study of the _________________________ Date: ____________ Facility: _______________ □ Other diagnostic testing: ______________________________________________________________ □ I HAVE NOT HAD ANY DIAGNOSTIC TESTS PERFORMED FOR MY CURRENT PAIN COMPLAINTS.
Pain Treatment History__________________________________________________________ Mark all of the following pain treatments you have undergone prior to today’s visit:
□ Chiropractic □ Physical Therapy □ Spine Surgery
□ Epidural Steroid Injection – (circle all levels that apply) Cervical/Thoracic/Lumbar
□ Joint Injection – Joint(s) ________________________________________________________________ □ Medial Branch Blocks of Facet Injection – (circle all levels that apply) Cervical/Thoracic/Lumbar
□ Radiofrequency Ablation – (circle all levels that apply) Cervical/Thoracic/Lumbar □ Spinal Column Stimulator – (circle one) Trial Only/ Permanent Implant
□ Vertebroplasty/ Kyphoplasty – Level(s) ___________________________________________________ □ Other: _____________________________________________________________________________ □ I HAVE NOT HAD ANY PRIOR TREATMENTS FOR MY CURRENT PAIN COMPLAINTS.
Current Medications ____________ ______________________________________________
Please indicate which (if any) of the following blood-thinners you are taking:
□ Aggrenox □ Coumadin/Warfarin □ Effient □ Lovenox □ Plavix □ Pletal □ Pradaxa □ Prasugrel □ Ticlid □ Other _______________________________________
Please list allmedications you are currently taking.
Medication Name Dose Frequency _____________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
