WORKMAN COMPENSATION INFORMATION FORM DATE: _______________
PATIENT NAME: ____________________________________ AGE: ______ BIRTHDATE: ____________
EMAIL: ______________________________ CELL PHONE: ( )___________ _________________
MALE FEMALE ADDRESS: _____________________________________________________________ CITY: __________________ STATE: ____________ ZIP: __________ PHONE ( ) __________________ SS#: ________________ OCCUPATION: _________________ CELL PHONE: ( ) ___________________ EMERGENCY CONTACT PERSON: ___________________________ PHONE: ( ) _________________ YOUR EMPLOYER: __________________________________WORK PHONE: ( ) _______________ EMPLOYER ADDRESS: _________________________________________________________________ CITY: _____________________ STATE: ______________ ZIP CODE: __________________________
WORKMAN COMPENSATION INFORMATION
DATE OF INJURY: _____________________ WHERE: _______________________________________ AREA(S) TO BE EXAMINED: ___________________________________________________________
___________________________________________________________ HAS ANOTHER PHYSICAIN TREATED YOU? YES NO IF YES, WHOM? _________________________ ANY PRIOR XRAYS OR MRI? YES NO if YES: WHAT FACILITY: _______________ DATE: __________ WHO REFERRED YOU TO THE SPORTS CLINIC: ____________________________________________ PRIOR EMPLOYMENT (PLEASE LIST ALL EMPOLYERS FOR LAST TEN YEARS
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
INDUSTRIAL INSURANCE CARRIER NAME: _______________________________________________
ADDRESS: ____________________________________________________________________________ CITY: _____________________ STATE: ________________ ZIP: ______________
ADJUSTER: ____________________________ ADJUSTER PHONE: __________________ CLAIM NUMBER: _______________________________ ADJUSTER FAX : ________________________ NOTES:
_____________________________________________________________________________________ _____________________________________________________________________________________
CONSENT TO RELEASE INFORMATION TO YOUR WORKMAN
COMPENSATION CARRIER
I, _____________________________________, HEREBY AUTHORIZE THE SPORTS CLINIC (NAME OF PATIENT)
ORTHOPEDIC MEDICAL ASSOICATES, INC. TO DISCLOSE ALL NECESSARY INFORMATION FROM MY HEALTH/HOSPITAL RECORES WHICH WERE OBTAINED DURING MY TREATMENT AT THIS FACILITY, DIRECTLY TO MY WORKMAN COMPENSATION CARRIER, IN ORDER TO RECEIVE REIMBURSEMENT FOR SERVICES RENDERED.
THIS CONSENT WILL BECOME EFFECTIVE IMMEDIATELY, AND REMAIN IN EFFECT UNTIL WRITTEN CANCELLATION IS RECEIVED.
MEDICAL HEALTH QUESTIONNAIRE
NAME________________________________AGE_______DATE OF BIRTH__________________ MALE____FEMALE_____WEIGHT_____HEIGHT______RIGHT OR LEFT HANDED (please circle) NAME OF INTERNIST/PRIMARY PHYSICIAN_________________________________________
PRIOR SIGNIFICANT MEDICAL ILLNESSES:
Diabetes .No Yes Heart Disease ..No Yes
Stroke .No Yes Tuberculosis No Yes
Cancer .No Yes Hepatitis ..No Yes
Rheumatic Fever .No Yes Other serious diseases_____________________
OPERATIONS:
Have you had any surgery No Yes Cataract ..No Yes
Tonsils ..No Yes Hysterectomy .No Yes
Hernia ...No Yes Other ..No Yes(please list)
Other surgeries:_________________________________________________________________
MEDICATIONS CURRENTLY TAKING:
Prescription drugs:
Name:__________________________________Dose__________________________________ Name:__________________________________Dose__________________________________ Name__________________________________Dose__________________________________ Over the counter drugs:
Name:_________________________________Dose___________________________________ Name;_________________________________Dose___________________________________ Name:_________________________________Dose___________________________________
Other drugs taken within past 6 months (circle one)
Dosage
Heart Medication Yes No __________
Anticoagulant . ...Yes No __________
Blood pressure medication . Yes No __________
Tranquilizers ..Yes No __________
Diuretics ..Yes No __________
Sleeping medications ..Yes No __________
Cortisone Yes No __________
Anti-inflammatory drugs Yes No __________
ALLERGIES AND SENSITIVITIES
Penicillin or other antibiotics . .Yes NoCodeine . ..Yes No
Sulfa Yes No
Aspirin Yes No
Iodine ..Yes No
Any foods such as milk, eggs, chocolate Yes No
SOCIAL HISTORY:
SINGLE ______ MARRIED ________ SEPARATED ______ DIVORCED ______ WIDOWED _________ ALCOHOLIC BEVERAGES: NEVER ___________ RARELY _____________Frequency _____________ TOBACCO: CIGARETTES _______ PACKS PER DAY CIGARS __________ PIPE __________ OCCUPATION: ____________________________________________________________________ RETIRED: YES ______ NO _________
FAMILY HISTORY:
FATHER: IF LIVING AGE____ IF DECEASED AGE _______ HEALTH ISSUES ________________________ MOTHER: IF LIVING AGE ____ IF DECEASED AGE _______ HEALTH ISSUES ________________________ BROTHER/SISTER: AGES __________________ HEALTH ISSUES ___________________________ HAS ANY BLOOD RELATIVE BEEN DIAGNOSED:
(PLEASE CIRCLE BELOW) CANCER
TUBERCULOSIS DIABETES HEART DISEASE
HIGH BLOOD PRESSURE STROKE
SEIZURES
BLEEDING TENDENCY GOUT
MEDICAL HISTORY 3 REVIEW OF SYSTEMS
(PLEASE CIRCLE YOUR POSITIVE RESPONSES)
GENERAL: RECENT WEIGHT CHANGE
CANCER TYPE ______________________________________________ SKIN: SKIN DISEASE ______________________________________________ EARNOSETHROAT; EYE DISEASE SINUS DISEASE EASY NOSEBLEEDS
IMPAIRED HEARING DIZZINESS
NECK: STIFFNESS THYROID DISEASE ENLARGED GLANDS LUNGS: ASTHMA SHORTNESS OF BREATH PNUEMNOIA
CARDIAC: CHEST PAINS HEART ATTACK HIGH BLOOD PRESSURE
GASTROINTESTINAL ULCERS GALLBLADDER DISEASE LIVER DISEASE
HEPATITIS HEMORRHOIDS ABNORMAL RECTAL BLEEDING GENITOURINARY LOSS OF URINE CONTROL FREQUENCY OF URINATION BURNING
BLOOD IN URINE KIDNEY DISEASE
GYNECOLOGICAL SPECIFIC PROBLEMS ______________________________
MUSCULOSKELETAL PRIOR FRACTURES _______________________________________ PRIOR SKELETAL INJURIES _________________________________
UROLOGIC PROSTATE HYPERTROPHY URINARY RETENTION
HEMATOLOGIC BLOOD DISEASES EXCESSIVE BLEEDING WITH SURGERY
• In sp ec tio ns an d C op ie s: th e rig ht to in sp ec t an d ob ta in co pi es of th e m ed ic al in fo rm at io n th at m ay be us ed to m ak e de ci si on s ab ou ty ou ,i nc lu di ng m ed ic al re co rd s, bi lli ng re co rd s, bu tn ot in cl ud in g ps yc ho th er ap y no te s. In or de r to in sp ec to r ob ta in re co rd s, yo u m us ts ub m it th e re qu es t in w ri tin g to th e ad dr es s on th e ba ck of th e br oc hu re . • A m en dm en t: th e rig ht to as k us to am en d yo ur m ed ic al in fo rm at io n if yo u be lie ve it is in co rr ec to r in co m pl et e, an d yo u m ay re qu es ta nd am en dm en tf or as lo ng as th e in fo rm at io n is ke pt by or fo r ou r or ga ni za tio n. Y ou m us tp ro vi de us w ith a re as on th at su pp or ts yo ur re qu es tf or am en dm en t. O ur or ga ni za tio n w ill de ny yo ur re qu es ti f yo u fa il to su bm it yo ur re qu es ta nd th e re as on fo r yo ur re qu es ti n w ri tin g to th e ad dr es s in th e ba ck of th is br oc hu re . A ls o, w e m ay de ny th e re qu es ti f yo u as k us to am en d in fo rm at io n th at is ac cu ra te an d co m pl et e; no tp ar to f th e in fo rm at io n ke pt by or fo r ou r or ga ni za tio n; no tp ar to f th e in fo rm at io n w hi ch yo u ar e pe rm itt ed to in sp ec ta nd co py ;n ot cr ea te d by ou r or ga ni za tio n, un le ss th e in di vi du al or en tit y th at cr ea te d th e in fo rm at io n is no t av ai la bl e to am en d th e in fo rm at io n. • A cc ou nt in g of D is cl os ur es :t he rig ht to re qu es ta n ac co un tin g of di sc lo su re s m ad e of yo ur m ed ic al in fo rm at io n to en tit ie s w ho m yo u do no th av e an es ta bl is he d re la tio ns hi p w ith . In or de r to ob ta in an ac co un tin g, yo u m us ts ub m it yo ur re qu es t in w ri tin g to th e ad dr es s on th e ba ck of th is br oc hu re .A ll re qu es ts m ay no tb e lo ng er th an 6 ye ar s an d m ay no ti nc lu de da te s pr io r to O ct ob er 16 ,2 00 2. T he fir st re qu es ti n a 12 m on th pe rio d is fr ee of ch ar ge .Y ou w ill be ch ar ge d fo r an y ad di tio na ll is ts re qu es te d in a 12 m on th pe rio d. • R ig ht to F ile a C om pl ai nt :I f yo u be lie ve yo ur ri gh ts ha ve be en vi ol at e, yo u m ay fil e a co m pl ai nt w ith ou r or ga ni za tio n or w ith th e Se cr et ar y of th e D ep ar tm en to f H ea lth an d H um an Se rv ic es .Y ou w ill no tb e pe na liz ed fo r fil in g th e co m pl ai nt . A ll co m pl ai nt s m us tb e su bm itt ed in w rit in g at th e ad dr es s lis te d be lo w . • R ig ht to P ro vi de an A ut ho ri za tio n of O th er us es an d D is cl os ur es :o ur or ga ni za tio n w ill ob ta in yo ur w rit te n au th or iz at io n fo r us es an d di sc lo su re s th at ar e no ti de nt ifi ed by th is no tic e or ar e no tp er m itt ed by ap pl ic ab le la w . A ny au th or iz at io n yo u pr ov id e to us re ga rd in g th e us e an d di sc lo su re if yo ur m ed ic al in fo rm at io n m ay be re vo ke d at an y tim e in w ri tin g. A ft er yo u re vo ke yo ur au th or iz at io n, w e w ill no lo ng er us e or di sc lo se yo ur m ed ic al in fo rm at io n fo r th e re as on s de sc rib ed in th e au th or iz at io n. O f co ur se ,w e w ill no tb e ab le to ta ke ba ck an y di sc lo su re s th at w e ha ve al re ad y m ad e w ith yo ur pe rm is si on . • R ig ht to a P ap er C op y of T hi s N ot ic e: yo u ar e en tit le d to re ce iv e a pa pe r co py of th is no tic e of pr iv ac y pr ac tic es . Y ou w ill be as ke d to si gn an ac kn ow le dg m en tp ro vi ng re ce ip to f th is N ot ic e of P riv ac y P ra ct ic es . T he Sp or ts C lin ic O rt ho pa ed ic M ed ic al A ss oc ia te s, In c. 23 96 1 C al le de M ag da le na ,S ui te 22 9 L ag un a H ill s, C A 92 65 3
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T he fo llo w in g de sc rib e th e di ff er en tw ay s in w hi ch w e m ay us e an d di sc lo se yo ur m ed ic al in fo rm at io n.1
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T re at m en t: in or de rt o tr ea ty ou an d m ay di sc lo se in fo rm at io n to ot he rs w ho as sis tw ith yo ur ca re or tr ea tm en t.2
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Pa ym en t:: in or de rt o bi ll an d co lle ct pa ym en t fo rs er vi ce s yo u re ce iv e fr om us .W e m ay us e an d di sc lo se in fo rm at io n to ob ta in pa ym en tf ro m th ird pa rt ie s th at m ay be re sp on sib le fo rs uc h co st s su ch as fa m ily m em be rs .W e m ay us e yo ur m ed ic al in fo rm at io n in or de rt o bi ll yo u di re ct ly fo rs er vi ce s an d ite m s.3
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H ea lth C ar e O pe ra tio ns : to op er at e ou r bu sin es st o en su re yo u re ce iv e qu al ity ca re an d to as su re ou ro rg an iz at io n is w el lr un .4
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A pp oi nt m en tR em in de rs : to re m in d yo u th at yo u ha ve an ap po in tm en ta tt he da yt im e nu m be r yo u pr ov id e us w ith .5
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T re at m en tA lte rn at iv es :t o in fo rm yo u of tr ea tm en ta lte rn at iv es an d/ or he al th re la te d be ne fit s an d se rv ic es th at m ay be ofin
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6
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Fu nd ra isi ng :i n or de rt o co nt ac ty ou as pa rt of fu nd ra isi ng ac tiv ity . W e m ay di sc lo se yo ur in fo rm at io n to a bu sin es s as so ci at e or to a fo un da tio n re la te d to ou ro rg an iz at io n to ra ise m on ey fo ro ur or ga ni za tio n. N am e an d ad dr es s on ly w ill be us ed .7
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M ar ke tin g: to m ak e a m ar ke tin g co m m un ic at io n to yo u th at oc cu rs in a fa ct -to -f ac e en co un te rw ith yo u; co nc er ns pr od uc ts or se rv ic es of no m in al va lu e; or co nc er ns ou rh ea lth -r el at ed pr od uc ts or se rv ic es ,o rt ho se of an ot he rp ar ty ,p ro vi de d th at w e te ll yo u th at w e ar e th e pa rt y co m m un ic at in g w ith yo u, an d te ll yo u if w e ha ve re ce iv ed ,o rw ill re ce iv e, di re ct ly or in di re ct ly ,a ny m on ey or ot he r re m un er at io n fo rm ak in g th e co m m un ic at io n to yo u.8
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R eq ui re d B y La w :w he n re qu ire d by ap pl ic ab le la w re ga rd in g cr im e or cr im in al co nd uc t; w ar ra nt , su m m on s, su bp oe na or le ga lp ro ce ss . If se rv ed w ith a le ga ls ub po en a fo rr ec or ds (c on ta in sa re le as e of re co rd s sig ne d by yo u or ve rb al au th or iz at io n ob ta in ed fr om yo u or yo ur at to rn ey of re co rd or pr oo fo fs er vi ce fr om th e re qu es tin g pa rt y) w e m us t ho no rt he re qu es t.9
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Pu bl ic H ea lth A ct iv iti es :t o co nt ro ld ise as e, in ju ry ,o rd isa bi lit y; m ai nt ai n vi ta lr ec or ds su ch as bi rt h or de at h; re po rt ch ild ab us e or ne gl ec t; ex po su re to co m m un ic ab le di se as e; dr ug re ac tio ns or FD A w ar ni ng s; re ca lle d de vi ce s or m ed ic at io ns . T o no tif y ap pr op ria te go ve rn m en ta ge nc ie s an d au th or iti es re ga rd in g th e po te nt ia la bu se or ne gl ec t of an ad ul tp at ie nt in cl ud in g do m es tic ab us e if th e pa tie nt ag re es or w e ar e re qu ire d or au th or iz ed by la w to do so .U nd er lim ite d ci rc um st an ce s, to yo ur em pl oy er fo rr el at ed w or kp la ce in ju ry or ill ne ss or m ed ic al su rv ei lla nc e.1
0
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C or on er s, M ed ic al E xa m in er s, an d Fu ne ra l D ire ct or s: as ne ed ed to ca rr y ou tt he ir du tie s re qu ire d by la w .1
1
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O rg an an d T iss ue D on at io n: to or ga ni za tio ns th at ha nd le or ga n an d tis su e pr oc ur em en t, ba nk in g or tr an sp la nt at io n.1
2
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R es ea rc h: su bj ec tt o sp ec ia la pp ro va lp ro ce ss , in fo rm at io n m ay be us ed on re se ar ch pr oj ec ts or st ud ie s. T he in fo rm at io n w ill no tl ea ve ou r pr em ise s.1
3
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Se rio us T hr ea ts to H ea lth O rS af et y: to re du ce or pr ev en ta se rio us th re at to yo ur he al th an d sa fe ty or th at of an ot he ri nd iv id ua lo rt he pu bl ic . W e w ill on ly di sc lo se to pe rs on s or or ga ni za tio ns ab le to he lp pr ev en tt he th re at .1
4
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Sp ec ia liz ed G ov er nm en tF un ct io ns :i fy ou ar e a m em be ro fU .S .o rf or ei gn m ili ta ry fo rc es (in cl ud in g ve te ra ns )a nd if re qu ire d by ap pr op ria te m ili ta ry co m m an d au th or iti es ;o rt o fe de ra lo ff ic ia ls fo ri nt el lig en ce an d na tio na ls ec ur ity .1
5
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W or ke rs C om pe ns at io n: ou ro rg an iz at io n w ill re le as e yo ur m ed ic al in fo rm at io n fo rw or ke rs co m pe ns at io n an d sim ila rp ro gr am st o al lp ar tie s as re qu ire d by st at e an d fe de ra ll aw .Y
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Y ou ha ve th e fo llo w in g ri gh ts re ga rd in g th e m ed ic al in fo rm at io n th at w e m ai nt ai n ab ou ty ou . W e ar e no tr eq ui re d to ag re e to yo ur re qu es t; ho w ev er ,i f w e do ag re e, w e ar e bo un d by ou r ag re em en te xc ep tw he n ot he rw is e re qu ire d by la w ,i n em er ge nc ie s, or w he n ne ce ss ar y to tr ea t yo u. In or de r to re qu es ta re st ri ct io n in ou r us e or di sc lo su re of yo ur m ed ic al in fo rm at io n ,y ou m us tm ak e yo ur re qu es ti n w ri tin g to th e ad dr es s on th e ba ck of th is br oc hu re . • R eq ue st in g R es tr ic tio ns :t he ri gh tt o re qu es t a re st ric tio n in ou r us e or di sc lo su re of yo ur m ed ic al in fo rm at io n fo r tr ea tm en t, pa ym en t or he al th ca re op er at io ns . Y ou ha ve th e ri gh tt o lim it ou r di sc lo su re to in di vi du al s in vo lv ed in yo ur ca re or th e pa ym en tf or yo ur ca re su ch as fa m ily m em be rs an d fr ie nd s. • C on fid en tia lC om m un ic at io ns :t he ri gh tt o re qu es to ur or ga ni za tio n co m m un ic at e w ith yo u ab ou ty ou r he al th an d re la te d is su es in a pa rt ic ul ar m an ne r or ce rt ai n lo ca tio ns w ith ou ts ta tin g a re as on fo r yo ur re qu es t.THE SPORTS CLINIC
ORTHOPEDIC MEDICAL ASSOCIATES, INC. 23961 Calle de la Magdalena #229 Laguna Hills, CA 92653
949-581-7001
PRIVACY RIGHTS NOTIFICATION AND ACKNOWLEDGEMENT
I hereby acknowledge that I have received the notice of Privacy Practices ((Patient Privacy Rights Notification)
Signature: ____________________________________________________
Print Name: ___________________________________________________
Date: __________________________
**This acknowledgement reflects the proposed modifications to s164.520 of the Privacy Standards as set forth by the Department of Health and Human Services at 67 Fed. Reg.14814 (March 27, 2002). It applies to health care providers with direct treatment relationships. This acknowledgement or some other form of acknowledgment (i.e. initials) must be on a cover sheet accompanied by the disclosure log, kept in a separate, visible place in the patient record, apart from the Medical PHI.
Secure Phone Option:
Is there a telephone number on which personal health information can be left on your message recording in the
event that you are not available when we call? YES NO
IF yes, what is the number: ______________________________ ____________________
THE SPORTS CLINC ORTHOPEDIC MEDICAL ASSOCIATES, INC. OFFICE POLICIES SIGNIN SHEET
1. FAILED APPOINTMENT CHARGE: We reserve the right to charge for each failed appointment not cancelled at least 24 hours before the scheduled appointment time.
THIS CHARGE IS NOT COVERED BY YOUR INSURANCE
2. FORMS COMPLETION CHARGE: All forms requiring completion, excluding disabled parking form, but including forms such as state disability forms, assisted living forms, insurance benefit forms, FMLA forms, leave of absence forms, health assessment forms, time off work forms specific to employers will be charged at $35 for up to two pages.
THIS CHARGE IS NOT COVERED BY YOUR INSURANCE
3 DICTATED LETTERS: Letters prepared for third parties excluding attorneys, (such as insurance companies, or employers) will be charged at $35 per page. All medical legal letters arranged between this office (Lynne) and your attorney will be charged on a case by case basis.
THIS CHARGE IS NOT COVERED BY YOUR INSURANCE
4. RETURNED CHECK CHARGE: All accounts with checks returned by the bank unpaid will be charged $50 per check. THIS CHARGE IS NOT COVERED BY YOUR INSURANCE
5. COPAYMENTS ARE REQUIRED AT THE TIME OF VISIT: This is a contractual obligation between you and your insurance company.
Failure to make copayments can lead to denial of insurance payments. We accept cash, credit cards (AMEX, MasterCard, Visa) and
checks.
THIS CHARGE IS NOT COVERED BY YOUR INSURANCE
6. COPY OF MEDICAL RECORDS: There is a charge for copying your medical records and transferring them to another physician. The charge is $35.00 and includes postage.
THIS CHARGE IS NOT COVERED BY YOUR INSURANCE
By signing this document, I acknowledge and agree to the above office policies.
Patient Name __________________________________________ DATE ______________________
Patient Signature: _________________________________________________________________________ Address: ________________________________________________________________________________ Phone: ______________________________ Email: _____________________________________________
ASSIGNMENT OF BENEFITS
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare benefits, private insurance, and any other health plan to:
The Sports Clinic Orthopaedic Medical Associates, Inc. 23961 Calle de la Magdalena #229
Laguna Hills, CA 92653
This assignment will remain in effect until revoked in writing by myself. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance.
I hereby authorize said assignee to release all information necessary to secure payment.
SIGNED: __________________________________________________________________
Printed Name: _______________________________________________________________
