Last updated 4/6/15 mkb
Is your injury work related?
Yes____ No____
Is your injury auto accident related?
Yes____ No____
If so, when was the Date Of Injury: _____________________
PATIENT INFORMATION
First Name: _____________________________________ Last Name: _________________________________________
Date of Birth: _______________Gender:___________ Marital Status: ______________ S.S.N. #:___________________
Language: _________________________Race:________________________ Ethnicity: ___________________________
Street Address: ________________________________ City:_________________ State:_______ Zip Code:___________
Home Phone: ___________________ Cell Phone: ___________________ Preferred Contact Method: _______________
Email Address: _____________________________________________________________________________________
Emergency Contact: __________________________ Relationship: __________________ Phone: __________________
Occupation: _______________________________________ Employer: _______________________________________
How did you hear about us? __________________________________________________________________________
PHYSICIAN & PHARMACY INFORMATION
Primary Care Doctor: ___________________________________ Phone: ______________________________________
Address: _____________________________________________ Fax: _________________________________________
City: _________________________________________________State: _______________________________________
Pharmacy: _____________________________Phone #: ___________________ Address: _________________________
INSURANCE INFORMATION
Primary Insurance
: ___________________________________________________________________________
Policy #: ________________________________________________ Group#:___________________________________
Subscriber Name: ________________________________________ Date of Birth: _______________________________
Secondary Insurance
: _________________________________________________________________________
Policy #:
___________________________________________
Group#:___________________________________
Subscriber Name: _______________________________________ Date of Birth: _______________________________
LEGAL GAURDIAN OR POWER OF ATTORNEY (if applicable)
First Name: ______________________________________ Last Name: ________________________________________
Date of Birth: _________________ Gender: ______________________ Relation to Patient: _______________________
Street Address: _____________________________________________________________________________________
City: __________________________________________ State: __________ Zip Code: ___________________________
Home Phone: ______________________ Cell Phone: ________________________ Work Phone: __________________
CONSENT FOR TREATMENT, AUTHORIZATION OF BENEFITS & INFORMATION RELEASE:
I hereby authorize those medical and/or surgical benefits otherwise payable to me for services rendered shall be paid directly to the physician(s) providing care. I hereby authorize Ronald S. Lederman, M.D., P.L.L.C. and my physician to release any information required by my insurance company to process claims. I am presenting myself to Ronald S Lederman, MD, PLLC, for evaluation, diagnosis, and/or treatment of a medical condition. I give consent and authorize my provider to order and/or perform all exams, tests, procedures, and any other care deemed necessary or advisable for the evaluation, diagnosis, and treatment of this medical condition. This consent is valid for each visit made to the office, unless and until revoked in writing.
X
_____________________________________________ _____ ___________________________
Patient/Guardian Signature Date
Revised 4/6/2015 mkb
Please complete every line item, as it is necessitated by regulations from the government
(Health Care Finance Administration-‐ HCFA)
Patient Name: __________________________________________________________ Date: ____ _________________
What are you being seen for today?
__________________________________________________________________________
Which side is affected?
Right & Left Right Left
Date of injury or start of pain:
________________________________________________________________________________
How did the pain occur? Injury Chronic Spontaneous Follow-‐up
Is this work related?
Yes No Last day of work? ______________________________
Is this the result of a motor vehicle accident? Yes No
Pain Description
Quality of your pain
None Mild Moderate Severe
Type of pain Sharp Dull Other: ____________________________________
Have you seen another physician for this injury? Yes No
If yes, who? _____________________________________________________________________________
What treatments have you tried?
Nothing Physical Therapy Brace Injections Surgeries Icing Other_______________
If surgery, please specify: _________________________________________________________
Daily Medications: Yes No *You
may attach a list of current medications in place of entering the information below *
Drug Name: _______________________Dosage_________________Frequency_____________ Drug Name: _______________________Dosage_________________Frequency_____________ Drug Name: _______________________Dosage_________________Frequency_____________ Drug Name: _______________________Dosage_________________Frequency_____________ Drug Name: _______________________Dosage_________________Frequency_____________ Drug Name: _______________________Dosage_________________Frequency_____________
Pain level: 0 1 2 3 4 5 6 7 8 9 10
(1-‐3 = Mild)
(4-‐7 = Moderate) (8-‐10 = Severe)
Have you had any testing? MRI EMG/NCS Bone/CAT Scan Other_____________________________
X____________________________________________________________________ Date _____________________
Patient/Guardian Signature
PH: 248-‐669-‐2000 2300 Haggerty Road, Suite 1110 W. Bloomfield, MI 48323 FAX: 248-‐669-‐2110
Last Updated 4/6/15 mkb
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
I authorize my physician and/or administrative and clinical staff to disclose the following protected health
information to:
Myself only
My spouse or significant other (specify name) ____________________________________________
My parent(s) (specify name(s)) ________________________________________________________
Attorney (name & phone number)
______________________________________________________________________________
Other (specify name & relation) _______________________________________________________
Information to be disclosed: All information
Laboratory results
X-‐Ray results/films
Diagnosis
Medications
Other ____________________ Dates of Service _________________________
I would like to be contacted at my:
Home phone ________________ Work phone ____________________________
Cell phone _________________ Email __________________________________
Please check the box below regarding the office staff or physician leaving information or confirming
appointments on my answering machine, voice mail or with my answering service:
No, I do not want any information left on my answering system.
Yes, I give my permission for only non-‐medical messages and appointment reminders
to be left on my answering system.
Yes, I give my permission for medical information, non-‐medical messages and appointment
reminders to be left on my answering system.
This authorization shall be in force and effective until revoked, at which time this authorization expires.
I understand that I have the right to revoke this authorization, in writing, at any time by sending such written
notification to the Privacy Officer at the below address. I understand that information used or disclosed
pursuant to this authorization may be disclosed by the recipient and may no longer be protected by the
federal HIPAA Privacy Rule or state law.
X
________________________________________ __________________________________________
Signature of Patient or Personal Representative
Date
_________________________________________ __________________________________________
Print Name of Patient or Personal Representative Description of Personal Representative
_________________________________________ __________________________________________
Date reviewed/updated Signature Date reviewed/updated Signature
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
Overview
The law requires us to keep your protected health information (“PHI”) private in accordance with this Notice of Privacy Practices (“Notice”), as long as this Notice remains in effect. We are also required to provide you with a paper copy of this Notice, which contains our privacy practices, our legal duties, and your rights concerning your PHI.
From time to time, we may revise our privacy practices and the terms of our Notice at any time, as permitted or required by applicable law. Such revisions to our privacy practices and our Notice may be retroactive. Our Notice will be updated and made available to our patients prior to any significant revisions of our privacy practices and policies.
Our Privacy Practices
Use and Disclosure: We may use or disclose your PHI for treatment, payment, or health care operations. For your convenience, we have provided the following examples of such potential uses or disclosures:
Treatment: Your PHI may be used by or disclosed to any physicians or other health care providers involved with the medical services provided to you.
Payment: Your PHI may be used or disclosed in order to collect payment for the medical services provided to you.
Health Care Operations: Your PHI may be used or disclosed as part of our internal health care operations. Such health care operations may include, among other things, quality of care audits of our staff and affiliates, conducting training programs, accreditation, certification, licensing, or credentialing activities.
Authorizations: We will not use or disclose your medical information for any reason except those described in this Notice, unless you provide us with a written authorization to do so. We may request such an authorization to use or disclose your PHI for any purpose, but you are not required to give us such authorization as a condition of your treatment. Any written authorization from you may be revoked by you in writing at any time, but such revocation will not affect any prior authorized uses or disclosures.
Patient Access: We will provide you with access to your PHI, as described below in the Individual Rights section of this Notice. With your permission, or in some emergencies, we may disclose your PHI to your family members, friends, or other people to aid in your treatment or the collection of payment. A disclosure of your PHI may also be made if we determine it is reasonably necessary or in your best interests for such purposes as allowing a person acting on your behalf to receive filled prescriptions, medical supplies, X rays, etc.
Locating Responsible Parties: Your PHI may be disclosed in order to locate, identify or notify a family member, your personal representative, or other person responsible for your care. If we determine in our reasonable professional judgment that you are capable of doing so, you will be given the opportunity to consent to or to prohibit or restrict the extent or recipients of such disclosure. If we determine that you are unable to provide such consent, we will limit the PHI disclosed to the minimum necessary.
Disasters: We may use or disclose your PHI to any public or private entity authorized by law or by its charter to assist in disaster relief efforts.
Deceased Persons: After your death, we may disclose your PHI to a coroner, medical examiner, funeral director, or organ procurement organization in limited circumstances.
Research: Your PHI may also be used or disclosed for research purposed only in those limited circumstances not requiring your written authorization, such as those which have been approved by an institutional review board that has established procedures for ensuring the privacy of your PHI.
Required by Law: We may use or disclose your medical information when we are required to do so by law. For example, your PHI may be released when required by privacy laws, workers’ compensation or similar laws, public health laws, court or administrative orders, subpoenas, certain discovery requests, or other laws, regulations or legal processes. Under certain circumstances, we may make limited disclosures of PHI directly to law enforcement officials or correctional institutions regarding an inmate, lawful detainee, suspect, fugitive, material witness, missing person, or a victim or suspected victim of abuse, neglect, domestic violence or other crimes. We may disclose your PHI to the extent reasonably necessary to avert a serious threat to your health or safety or the health or safety of others. We may disclose your PHI when necessary to assist law enforcement officials to capture a third party who has admitted to a crime against you or who has escaped from lawful custody.
Military and National Security: We may disclose to military authorities the medical information of Armed Forces personnel under certain circumstances. When required by law, we may disclose your PHI for intelligence, counterintelligence, and other national security activities.
Your Individual Rights
Access and Copies: In most cases, you have the right to review or to purchase copies of your PHI by requesting access or copies in writing to our Privacy Officer. Please contact our Privacy Officer regarding our copying fees.
Disclosure Accounting: You have the right to receive an accounting of the instances, if any, in which your PHI was disclosed for purposes other than those described in the following sections above: Use and Disclosures, Facility Directories, Patient Access, and Locating Responsible Parties. For each 12-‐month period, you have the right to receive one free copy of an accounting certain details surrounding such disclosures that occurred after April 13, 2003. If you request a disclosure accounting more than once in a 12-‐ month period, we will charge you a reasonable, cost-‐based fee for each additional request. Please contact our Privacy Officer regarding these fees.
Additional Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your PHI, but we are not required to honor such a request. We will be bound by such restrictions only if we agree to do so in writing signed by our Privacy Officer.
Alternate Communications: You have the right to request that we communicate with you about your PHI by alternate means or in alternative locations. We will accommodate any reasonable request if it specifies in writing the alternative means or location, and provides a satisfactory explanation of how future payments will be handled.
Amendments to PHI: You have the right to request that we amend your PHI. Any such request must be in writing and contain a detailed explanation for the requested amendment. Under certain circumstances, we may deny your request but will provide you a written explanation of the denial. You have the right to send us a statement of disagreement to which we may prepare a rebuttal, a copy of which will be provided to you at no cost. Please contact our Privacy Officer with any further questions about amending your medical record.
Complaints
If you believe we have violated your privacy rights, you may complain to us or to the Secretary of the U.S. Department of Health and Human Services. You may file a complaint with us by notifying our Privacy Officer.
We support your right to protect the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact us:
Meghan Brunner, Office Manager 2300 Haggerty Road, Suite 1110 West Bloomfield, MI 48323
ACKNOWLEDGEMENT OF RECEIPT OF THE NOTICE OF PRIVACY PRACTICES
I, the undersigned Patient or legally authorized representative (“Agent”) of the Patient acknowledges that he or she personally received a copy of the Ronald S. Lederman’s Notice of Privacy Policies on the date indicated below.
Signature: X _________________________________________________________ Date: __________________
Patient Name: __________________________________________________________________________________
Last Updated 4/6/15 mkbLast updated 4/6/15 mkb
PATIENT PAYMENT AGREEMENT
______ Non-‐Network / Non-‐Participating Provider
I understand that I am choosing to be seen by a non-‐network or non-‐participating provider. I realize
that my insurance carrier may cover only limited services or may choose to deny the service in full. I
acknowledge that I will be financially responsible for any services not covered in whole or in part by my
insurance carrier.
______ No Referral / Authorization on File
I understand that I am choosing to be seen without referral and / or authorization from my primary
care physician or insurance carrier. Without proper authorization, I realize my insurance carrier will
not reimburse the physician for services rendered. I acknowledge that I will be financially responsible
for any and all services provided.
______Unable to Verify Insurance / Open Claim
I understand that I am choosing to be seen without verification of coverage for services rendered. I
understand that I am held financially responsible for any and all services rendered and that payment
for such services is payable at the time of service. I agree to seek direct reimbursement from my
insurance carrier / payer, and am entitled to an itemized receipt of all services rendered and paid, for
such purpose.
______Private Pay / Patient Pay
I understand that I am financially responsible for any and all services rendered and that payment for
such services is due and payable at the time the service is rendered.
______Not Insurance Provider
I understand that Ronald S Lederman MD PLLC is not a provider for _____________________________
insurance and WILL NOT bill any services to said insurance company. I also understand I am financially
responsible for all services.
Due to the constant changes in health insurance, we are able to verify your health care coverage
however we are unable to guarantee payment of benefits.
______Payment of Benefits
I understand that I am financially responsible for any and all services that are rendered if my
health insurance is not active or payable at time of service.
X
________________________________________________
____________________
Last Updated 4/6/15 mkb
OFFICE & FINANCIAL POLICIES
Welcome and thank you for choosing Ronald S. Lederman, M.D., P.L.L.C. for your orthopaedic care. We are committed to providing you with the highest quality medical care, in an efficient, timely and cost-‐effective manner. We hope that by providing you with our policies in advance we can prevent any misunderstanding at the time of your visit.
The patient is responsible for knowing their insurance benefit coverage and whether a referral is needed for specialist visits. We will gladly file your insurance claim on your behalf. We allow 30 days from the date a claim is filed for the insurance company to pay. If the insurance carrier does NOT pay within this time, you will be responsible for the entire balance. We will not become involved in disputes between you and your insurance company regarding coverage and/or policy benefits, deductibles, non-‐covered services, co-‐insurance, coordination of benefits, pre-‐existing conditions or reasonable and customary charges, other than to supply factual information when necessary. You are responsible for the timely payment of your account by either yourself or your insurance company. It is your
responsibility to confirm with your insurance company that the physician is currently under contract with your plan. If your plan requires that you have a referral prior to seeing a specialist, please contact your primary care physician so that you will have the referral in hand at the time of your appointment. We accept faxed referrals (F:248.669.2110). If we do not have your referral on the appointment date, we will need to reschedule your visit, unless you choose to be seen without using your insurance benefits and pay for your visit in full.
Self-‐Pay Patients: New Patients presenting without insurance are required to pre-‐pay a deposit of $200.00. Depending on services rendered, the patient will receive a same day refund for any overpayment or will receive a balance due bill upon check-‐out.
Check-‐In: New patients should arrive 15 minutes prior to appointment time to complete paperwork. Bring your current insurance card with you on EACH VISIT. Without the insurance card we will be unable to file your insurance and you will be responsible for the charges for the day. On follow-‐up visits you will be asked to verify demographic and insurance information so that our records remain up-‐to-‐date.
Check-‐Out: Please be prepared to pay for the current visit as well as any past balances on your account. Co-‐pays, deductibles or fees for non-‐covered services will be required at the time of service. For your convenience, we take cash, check, MasterCard, Visa, American Express and Discover.
Late Arrivals: We do our best to keep to the schedule. When a patient arrives late it is impossible to stay on schedule. If you arrive more than 15 minutes past your scheduled appointment time you will be rescheduled so that other patients are not inconvenienced.
No Shows and Late Cancellations: We require a 24-‐hour advance notice if you must cancel your appointment. For your convenience we will call you 48 hours prior to your appointment. If you cancel on the same day as your appointment you will be considered a NO SHOW for that visit. Each patient is allowed one NO SHOW without penalty. The second NO SHOW will result in a $50.00 charge to your account.
Non-‐Covered Services: An “Insurance Waiver” may be required to acknowledge understanding of your responsibility for paying for non-‐ covered services. There are procedures/supplies that are considered by Medicare and private insurers as non-‐covered. If you are coming in for a non-‐covered service, please be prepared to pay for the service in full.
Telephone Communications: I give my express permission to Ronald S. Lederman MD PLLC and its Affiliates or contractors to contact me for any purpose at the current or any future numbers that are provided for my landline telephone, cellular telephone or any wireless device including the use of automated dialing equipment, prerecorded voice, or text message.
Minors: The parent(s) or guardian (s) accompanying a minor are responsible for providing current insurance information for the minor and/or payment in full for services provided. Unaccompanied minors must have a written authorization for medical treatment signed by the parent or guardian before treatment can be rendered.
I have read, understand and agree to the above office and financial policies. I hereby attest that I agree to provide current demographic and insurance information and authorize release of information necessary for insurance filing and pre-‐certification by signing this statement.
