have entrusted your care with us. InterMed prides itself on providing the highest quality health care to patients from childhood to senior stages of life.
In order to best serve your needs and enhance your visit, we have enclosed paperwork for you to complete and present at your initial appointment. Below are the descriptions and/or instructions for each enclosure:
o Enclosure 1: Authorization to Release Health Care Information
This form authorizes your previously treating providers to send us important information regarding your medical history. Please complete this form and return it to our Health Information department.
o Enclosures 2-3: Patient Notification Form and Medical History Form Thoroughly complete these forms and present them at your initial appointment. o Enclosures 4-5: Organizational Policies and Financial Policy
The enclosures are informational only, no action is necessary.
Please bring your health insurance card and state issued photo identification to your
appointment. Your specialist office co-payment will be due at the time of your visit. Please note, if you are covered by an HMO plan, a referral from your Primary Care Provider must be in place.
We encourage you to visit our website at www.intermed.com to learn more about InterMed and the services we provide. We look forward to meeting you!
InterMed Sports Medicine Team Appointment Date/Time:
Address: 100 Foden Road East Building, South Portland, ME Phone Number: (207) 523-8500
Parking: Free and onsite Directions:
From North: Merge onto I-95 North, Take the exit 45 toward US-1/Maine Mall Rd, Take the Maine Mall Rd exit toward ME-114/Jetport, Take the ramp toward Jetport, Merge onto Maine Mall Rd. Turn right onto Gorham Rd, Turn Left onto Foden Rd, 100 Foden Rd is on the Right.
From South: Merge onto I-295 South, Take the ME-9/Westbrook St exit, Exit 3, toward Jetport, Stay straight on Gorham Rd until you reach Dunkin Donuts on your Right, Turn Right onto Foden Rd, 100 Foden Rd is on the Right.
AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION If this form is not filled out in its entirety it may result in a delay in processing.
Patient Name_________________________________DOB_______________Telephone__________________ Address___________________________________________________________________________________
I understand that health care information is confidential and will not be released without my authorization unless permitted by law. I understand that I have the right to refuse authorization to disclose all or some health care information, but refusal may result in improper diagnosis or treatment, denial of insurance coverage, or other adverse consequences.
I hereby grant my permission for the authorized employees or agents to release my protected health information. Where Records are being Transferred From: To:
Physician/Individual: _________________________ Physician: InterMed, P.A. Address: ___________________________________ Address: 100 Foden Road, Suite 203 City/State: __________________________________ City/State: South Portland, Maine 04106
Phone: ____________________________________ Phone: 207-523-3745 (Health Information)
Fax: _______________________________________ Fax: 207-523-8581
By law, providers are required to release the minimum amount of information necessary to carry out the purpose of a release. Check the box/boxes and use the line beside each document type below to indicate the date or range of dates for written
Last 5 years of health records
information to be disclosed under this authorization as appropriate.
Physical Exams:___________________________ Progress Notes:___________________________
The information and material above may only be used for the following purpose(s):
( ) Transfer of Care: Reason for Transfer: ________________________________________________________________ ( ) WC Claim ( ) Ins. Application ( ) Legal Matter(s) ( ) Disability/FMLA ( ) Coordination of Care (NOT Transferring care)
I understand that my specific consent is necessary to disclose information pertaining to treatment and/or diagnosis of mental health conditions, substance abuse and/or HIV status. I understand that authorizing the release of such information does not confirm the existence of such history or treatment.
Please check the following specific authorizations:
AIDS/HIV I DO authorize____ I DO NOT authorize___
Alcohol and /or Drug Abuse Treatment I DO authorize____ I DO NOT authorize___
Mental Health Treatment I DO authorize____ I DO NOT authorize___
This authorization expires (12) months from the date hereof. I have the right to revoke this authorization in writing at any time. Revocation will not cover information/material released prior to that date, but will prevent further release of information. I understand that revocation may be the basis for denial of health benefits or other insurance coverage or benefits.
My signature below indicates that I have read this release form and have had all of my questions answered, if any. • I understand what this form authorizes.
• I consent to the release of information as recorded on this form.
• I authorize the party (ies) listed in section 1 of this form to make subsequent disclosures to the same recipient pursuant to this authorization.
• I understand that information released might be further released by the receiving party and that if this occurs, InterMed cannot guarantee the protection of this information once disclosed.
• I understand that I have a right to request a copy of the authorization.
X____________________________________________________________________ __________________________________ Patient or Representative Signature Date
Parent Legal Guardian Other Legally Authorized Representative (specify):___________________________________ 100 Foden Road West, Suite 203 South. Portland, ME 04106 Tel: 207-523-3745 Fax: 207-523-8581
Radiology Films/Reports: __________________ Consults: _______________________________ Ongoing Verbal Communication: ____________ Other (specify):___________________________
Patient Notification Form
Patient’s Legal Name: ____________________________________________ Date of Birth: ______________
First MI Last
Patient’s Mailing Address: ________________________________________________________________________ If applicable, Name of Parent(s), Legal Guardian(s): ________________________________________________
Circle One Circle One Cell (____) ___________________ Okay to leave message? Yes/No **Detailed Message? Yes/No Home (____) __________________ Okay to leave message? Yes/No **Detailed Message? Yes/No Work (____) __________________ Okay to leave message? Yes/No **Detailed Message? Yes/No
**Detailed messages may contain medical and/or prescription information.
Patient’s Marital Status (Circle One) Single Married Partner Divorced Widowed Patient’s Primary Care Physician: _______________________
Patient’s Employer: ___________________________________ Occupation: ________________________ Patient’s Health Insurance Company: ____________________ Policy Number: _____________________ Emergency Contact Name: ______________________________ Relationship: _______________________ Emergency Telephone: Cell (____) _____________ Home (____) _____________ Work (___) ___________ Select One:
I do not want any information about my healthcare communicated to family members/caregivers. I give InterMed permission to verbally communicate to family members/caregivers listed below.
Name:____________________ Name:_____________________ Name:_____________________ Please check the box next to the specific information that may be verbally
Prescription Request Request/Confirm/Cancel Appointments
communicated to the individual(s) listed above:
Referral Request Other (specify): ______________________________ This authorization expires (12) months from the date hereof. I have the right to revoke this authorization in writing at any time. Revocation will not cover information/material released prior to that date, but will present further release of information.
If you would like to grant permission to InterMed to discuss AIDS/HIV, Alcohol and/or Drug Abuse, or Mental Health with anyone but yourself, please request a Medical Release Form.
Patient Signature: ___________________________________________________Date: ___________________ Parent/Legal Guardian Signature: ______________________________________ Date: ___________________
Data entered into eCW Office Use Only Insurance card scanned
PLEASE BRING THIS COMPLETED QUESTIONAIRE WITH YOU TO YOUR SPORTS MEDICINE APPOINTMENT
Name: ____________________________________ Date of Birth: ____/____/____ Date of visit: ___/___/___ What is your current occupation? ______________________________________________________________ Who referred you to InterMed Sports Medicine? __________________________________________________ Who is your primary care provider? ____________________________________________________________
InterMed Staff Only:
I have reviewed the past medical history, past surgical history, medications, ROS, allergies, social history and family history with this patient.
Physician Signature: _______________________________________ Date: _________________________
BURNING X NUMBNESS O PINS & NEEDLES = STABBING / ACHE ^ Right Right Front Back
WHERE IS YOUR CURRENT INJURY / PROBLEM?
Use appropriate symbols shown below to mark the areas on your body where you feel these described sensations. Include ALL areas affected by your pain, and mark the type and area of
pain if it radiates or spreads to other areas.
Name: ____________________________________ Date of Birth: ____/____/____ Page 2 □ Poor sleep □ Fever □ Sweats □ Rash □ Chills □ Appetite changes □ Undesired weight loss □ Undesired weight gain Head and neck
□ Swelling/lumps in neck Hematologic
□ Lymph node enlargement □ Bleeding disorder □ Frequent infections Psychological □ Feeling depressed □ Feeling anxious Pulmonary-chest □ Difficulty breathing □ Chronic cough □ Wheezing □ Irregular heartbeat □ Poor exercise tolerance □ Swelling in the legs □ Leg cramps with walking Genitourinary
□ Wetting pants or bed □ Blood in urine □ Painful urination □ Urinary infections □ Pelvic Pain □ Sexual difficulties □ Menstrual problems Dermatologic □ Color changes □ Rashes □ Blisters □ Open sores □ Hair changes
□ Gastric reflux “heartburn” □ Constipation
□ Change in bowel habits □ Nausea / Vomiting □ Blood in stool Orthopaedic Problems □ Joint pain □ Swelling in joints □ Walking difficulty □ Muscle pain Neurological □ Headaches □ Numbness □ Balance problems □ Dizziness □ Weakness □ Paralysis
Please list participation in sports, exercise and other recreational activities.
__________________________________________________________________________________________ Briefly describe the nature of your injury/problem you are being seen for today.
__________________________________________________________________________________________ Please check any of the following symptoms you are experiencing with your injury/problem:
□Troubling climbing stairs
□Pain at bedtime
Approximate date your injury or your current problem began: _______________________________________ List the NAMES & DATES of providers who have treated you for your injury/current problem.
(Circle names of providers who continue to treat you.)
Nobody has treated me for my injury/current problem
Name: ____________________________________ Date of Birth: ____/____/____ Page 3 DIAGNOSTIC TESTS: Please check if you have EVER had any of the following for your injury/current problem.
I have had no diagnostic tests
□ X-rays Where?
□ CT scan □ MRI scan □ Bone Scan
□ EMG/Nerve Conduction study □ Other:
OTHER TREATMENTS: Check any you have had for your current problem. □ I have had no treatments
Still Using? Has it helped?
□ Physical Therapy □ Yes □ No □ Better □ Worse □ No change
□ Chiropractic Manipulation □ Yes □ No □ Better □ Worse □ No change □ Osteopathic Manipulation □ Yes □ No □ Better □ Worse □ No change
□ Massage Therapy □ Yes □ No □ Better □ Worse □ No change
□ Cortisone Injections □ Yes □ No □ Better □ Worse □ No change
□ Other Injections □ Yes □ No □ Better □ Worse □ No change
□ Acupuncture □ Yes □ No □ Better □ Worse □ No change
□ Other: □ Yes □ No □ Better □ Worse □ No change
Please continue ONLY if your
Primary Care Provider is not
List drug ALLERGIES or prior bad drug reactions: I have no known medication allergies or reactions.
Medication Name (prescription or over-the-counter) Nature of allergy or reaction
□No Shellfish allergy?
I have never used tobacco in any form.
□I have never used alcohol. TOBACCO / ALCOHOL USE HISTORY:
Do you smoke or use other forms of tobacco NOW?
□ Yes □ No Do you drink alcoholic beverages in any form?
□ Yes □ No If yes, how long have you used it? Average number of drinks per
week? Have you QUIT smoking or using other
forms of tobacco?
Name: ____________________________________ Date of Birth: ____/____/____ Page 4 Medical problem(s)
□ Heart disease/heart attack □ High blood pressure
□ Bleeding/Blood clotting problem □ Gastroesophageal reflux disease □ Anemia or blood diseases
□ Depression or mental/nervous problems □ Chronic Fatigue Syndrome
□ Cancer type(s) & location(s):
□ Strokes or “TIA” □ Seizures □ Multiple sclerosis □ Headache □ Osteoporosis □ Thyroid problems □ Stomach ulcers □ Kidney disease □ Diabetes
□ Liver disease or hepatitis □ Asthma or lung disease □ High cholesterol □ Chronic infections □ Arthritis (of any kind) □ Fibromyalgia
□ Other: ______________
MEDICATIONS: List all medications, vitamins or supplements you are taking. I take no medications or supplements.
Medication name Dosage Prescribing Doctor Why?
PAST SURGICAL HISTORY: Have you had any surgery? If so, please list below. I have had no surgeries.
Type of surgery? Surgeon name? When? Where?
FAMILY MEDICAL HISTORY (include blood relatives only): Medical conditions/Medical history: Mother
Welcome! The following information explains some of the policies our office uses. Answering Service
Our phones are live Monday through Friday from 8:00 am until 4:30 pm. By calling 207- 523-8500 you will be connected to our office or our answering service. This is the only number that will be answered by our service after normal office hours. If a call is placed after 4:30 pm the answering service will page the physician on call or contact our weekend clinic if applicable. The physician on call will respond to calls in order of priority. If you do not receive a call back within twenty (20) minutes of placing the call to our answering service, please call again and let the answering service know you have not received a call back.
Cancellations and Missed Appointments
Our office attempts to make reminder calls 24-48 hours in advance of scheduled appointments. Should you need to cancel or reschedule an appointment, we require at least 24 hours notice in order to make the time available to another patient. The third time an appointment is missed or cancelled without proper notice within an 18 month period, it may be necessary for us to consider discharge from the practice.
New patients who miss or cancel their initial appointment twice without providing proper notification shall be discharged from InterMed’s Sports Medicine practice.
We ask patients to contact their pharmacies first to fill all ongoing prescriptions. The pharmacy will then fax a request to our office which we will fax back before the end of the current business day. If this is a request for a new medication then we ask you to contact your physician’s office to obtain prescription refills. When requesting a refill, call (207) 523-8500 between the hours of 8:00 am-4:30 pm. Having the following information at the time of the call would be helpful:
o The medication you are in need of with correct dosage, frequency taken, and quantity requesting.
o The name and location of pharmacy.
Please allow us until the end of the business day (5:30 pm) to fulfill all prescription requests. If we have any questions we will call you back, otherwise please assume the pharmacy has your refill.
Reporting of Test Results
We make every attempt to report test results as soon as they are received. Different tests take varying amounts of time for results to be received. Feel free to ask your physician or their clinical assistant the timeframe in which they expect to receive your results. Once the results have been received, you will be notified by the physician or their clinical assistant via mail, phone or online patient portal. If for any reason you do not receive communication regarding results on a test after two weeks please contact our office.
Patient Financial Policy
The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due and payable at the time of service.
Insurance Verification and Co-payments
Self-pay accounts shall exist if a patient has no insurance coverage; there is no insurance card on file, or if the patient has not met his/her yearly deductible or coinsurance. Payment is expected at the time of service. Alternatively for large balances, a payment plan may be worked out with authorized personnel in the Billing Office.
Thirty (30) days from the date of the first statement a patient’s claim balance will be considered past due. If a patient is unable to pay their balance in full within the thirty (30) days the patients need to call the InterMed Billing Office at 207-828-0361 to setup a payment plan. If a patient’s claim balance becomes 180 days past due the balance will automatically be transferred to the Thomas Collection Agency. At that time patients will need to contact the Thomas Collection Agency (207-772-4659) for payment options.
Patient Collection Policy
As a service and courtesy to our established patients, non-participating health insurance plans will be billed as a non-assigned claim. Any outstanding balances are the responsibility of the patient.
Non-participating Insurance Plans
It is the responsibility of the patient to call and cancel scheduled appointments within 24 hours of the
appointment. If appointments are not cancelled within 24 hours, InterMed shall reserve the right to charge for the no-show.
Patients shall be financially responsible for medical services related to an accident. InterMed will submit claims to the patient’s health insurance carrier. All outstanding balances will be the responsibility of the patient.
Patients are responsible for notifying InterMed that certain treatment is injury related. Furthermore, the patient is responsible for supplying InterMed with the appropriate billing information, i.e. insurer, claim #, date of injury, etc.
Workers Compensation Cases
In order for a patient refund to be issued, there must be no outstanding insurance or patient balances. InterMed will process a refund request within 4 – 6 weeks.
Any returned check from the bank for non-payment (insufficient funds) shall result in the patient’s account being assessed a $15 fee per check returned.
Unless otherwise notified and accepted by InterMed, the custodial parent shall be responsible for all outstanding charges and balances. If the parents share custody (joint custody), unless otherwise agreed by the parties, the parent with the first birthday of the year will have the responsibility for any outstanding charges and balances. InterMed will bill the insurance carrier for both custodial and non-custodial parents.
Child Custody Cases
If your insurance requires you to chose a primary care physician (PCP), you may need to have a prior authorization completed by your PCP prior to seeing an InterMed Specialist (Audiology, Cardiology, Dermatology, ENT, OB/GYN, Physical Therapy, Sports Medicine and certain ancillary services). It is the patient’s responsibility to ensure a prior authorization is obtained. All charges incurred without a required prior authorization will be the responsibility of the patient.