test new Office Intake Form Step 1 of 4 25% PATIENT REGISTRATION/DEMOGRAPHICSSection A - PATIENT INFORMATIONPLEASE COMPLETE ALL ENTRIESPatient First Name*Patient Last Name*Patient Social #*GenderMaleFemaleBirth Date* Date Format: MM slash DD slash YYYY AgeAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Main Phone*Cell PhoneWork PhoneAuthorization to leave voice message Yes Email* Parent/Guardian First Last Parent/Guardian Social #:Relationship to Patient:Parent/Guardian Birth Date Date Format: MM slash DD slash YYYY Referring PhysicianReferring Physician Phone NumberPrimary PhysicianPrimary Physician Phone NumberEmergency ContactRelationshipEmergency Contact PhoneEmployer/School/Team Name PATIENT MEDICAL HISTORYHeightWeightPreferred Pharmacy and Pharmacy phone numberAllergies None / No Known Allergies ALLERGIES(Please list all allergies)FAMILY HISTORY (please check if applicable)Family History FAMILY HISTORY UNKNOWN Anesthesia Problems Mother Father Brother Sister Arthritis Mother Father Brother Sister Cancer Mother Father Brother Sister Diabetes Mother Father Brother Sister Heart Problems Mother Father Brother Sister Hypertension Mother Father Brother Sister Stroke Mother Father Brother Sister Thyroid Disorder Mother Father Brother Sister SOCIAL HISTORYMarital statusSingleMarriedDivorcedWidowedSeparatedOccupation Retired Disabled OccupationDisabled (Reason)How often do you drink alcohol?NeverDailyWeeklyInfrequentlyAre you a recovering alcoholic? Yes Do you use tobacco?NoYesWhat type of tobacco do you use? Cigarettes Chew Other How many packs of cigarettes per day?Any chance of Pregnancy?NoYesHow many months?SURGICAL HISTORY: Please list any surgeries you have had.SurgeriesPlease include: Type of Surgery Year or Date DoctorHave you EVER had any of the following?Check only those that apply. Infection/Infectious Disease Blood Clots Diabetes High Blood Pressure Heart Attack Heart Disease Pacemaker Headaches Kidney Stones Kidney Disease HIV/AIDS Hepatitis Stomach Ulcer Liver Disease Heart Palpitations Arthritis Heart Surgery Chest Pain/Angina Cancer Thyroid Disease Seizures Stroke Congestive Heart Failure Asthma Depression Osteoporosis Tuberculosis Peripheral Vascular Disease List any other medical conditionsREVIEW OF SYMPTOMSGeneral SymptomsCheck only those that apply. Chills Dizziness Fainting Fever Night Sweats Sleeping Problems Thirst – Excessive Weight Gain Weight Loss GASTROINTESTINAL SymptomsCheck only those that apply. Bowel Changes Constipation Diarrhea Vomiting Nausea NEUROLOGICAL SymptomsCheck only those that apply. Coordination Problems Learning Disabilities Speech Problems Convulsions Seizures Light-headedness Memory Loss Numbness / Tingling Paralysis Tremors MENTAL HEALTH SymptomsCheck only those that apply. Anxiety Loss of Interest Depression SKIN SymptomsCheck only those that apply. Dry/Sensitive Skin Hives Rash Scars Bruises Easily GENITOURINARY SymptomsCheck only those that apply. Lack of Bladder Control Blood in Urine Painful Urination Frequent Urination CARDIOVASCULAR SymptomsCheck only those that apply. Chest Pains Swelling of Ankles Rapid Heart Beat Irregular Heart Beat Circulation Problems Varicose Veins Heart Palpitations ENT SymptomsCheck only those that apply. Bleeding Gums Blurred Vision Crossed Eyes Difficulty Swallowing Double Vision Earaches Ear Discharge Hay Fever Hoarseness Sinus Problems Hearing Loss Nose-Bleeds Persistent Cough Persistent Runny Nose Ringing in Ears Recurring Sore Throat RESPIRATORY SymptomsCheck only those that apply. Coughing Coughing up Blood Shortness of Breath Wheezing List any other medical symptomsCURRENT MEDICATIONS: List any medications you are currently taking, please include over the counter medicationsMedicationsPlease include: Medication Name Dosage Prescribing DoctorDo you have a pain management contract in place?NoYesProvide doctor information for pain management contract INTAKE FORMAre you right or left handed?LeftRightAmbidextrousWhat body part are you being treated for today?*please choose ONLY one per office visit consultation Right Shoulder Left Shoulder Right Elbow Left Elbow Right Wrist/Hand Left Wrist/Hand Right Hip Left Hip Right Knee Left Knee Right Ankle Left Ankle Right Foot Left Foot Other Otherplease note what ONE area of the body hurts if not listed aboveWhat is your pain on a scale of 1-10?*Not Painful 1 2 3 4 5 6 7 8 9 10 Severe Pain12345678910What date did this begin? Date Format: MM slash DD slash YYYY Briefly describe the injury and location of the injuryHave you had previous treatment?*NoYesPlease describe the treatmentHave you had a X-ray?*NoYesWhich facility have you had the x-ray at?Have you had a MRI?*NoYesWhich facility have you had the MRI at?Have you had an Injection treatment?*NoYesWhen did you have the Injection treatment? Date Format: MM slash DD slash YYYY Have you done physical therapy for this problem?*NoYesWhen did you last do physical therapy for this problem? Date Format: MM slash DD slash YYYY Please describe your pain(i.e. dull, sharp, burning, aching)Please describe any mechanical symptoms(i.e. catching, locking, giving way, etc.)What makes your pain feel worse?(i.e. specific activities, positions, motions, etc.)What makes your pain feel better?(i.e. rest, ice, Tylenol, Ibuprofen, etc.) Section B. – HOW DID YOU HEAR OF US?Help us by letting us know how you heard about Integrated Orthopedics.How did you hear about us?Check all that apply ZocDoc Our Blog Our Monthly Newsletter I am a former / returning patient Our Integrated Orthopedics Website Referral from a friend or family member PRP Procedure Information from our website Google Bing Yahoo Instagram Snapchat Facebook Pinterest YouTube Doctor Referral Urgent Care Clinic Postcard / info I picked up at a local venue or Health Expo. Other Doctor ReferralPlease tell us the Doctor’s nameUrgent Care ClinicPlease tell us what clinic referred youPostcard / infoPlease tell us where you received this.OtherPlease list the other places which you heard about us.Section C. – PHOTOGRAPHY & VIDEO RELEASEI hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or videotape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material will be used online within an unrestricted geographic area. Photographic, audio or video recordings may be used for the following purposes: • Online – posted on the website for Integrated Orthopedics • Conference or other educational presentations conducted by Integrated Orthopedics healthcare professionals (physician, PA, PT, etc) By signing this release, I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in a public educational setting. I will be consulted about the use of the photographs or video recording for any purpose other than those listed above. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only. By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for the purposes stated in this release.Photograph & Video Release Form I AGREE I DECLINE Section D. – INSURANCE / PAYMENTInsurance Information (Required, even if insurance card is on file)Primary Insurance: (If Lien, Work Comp or Self Pay enter that as Insurance Co Name)Insurance Co Name*Policy HolderRelationship to PatientPolicy Holder Birth Date Date Format: MM slash DD slash YYYY EmployerSecondary Insurance:Insurance Co NamePolicy HolderRelationship to PatientPolicy Holder Birth Date Date Format: MM slash DD slash YYYY EmployerAUTHORIZATION TO RELEASE PATIENT INFORMATION: I hereby authorize Integrated Orthopedics to release any personal health information (PHI) required in the course of my examination or treatment to the above stated insurance company, or their affiliates.* I AGREE AUTHORIZATION TO PAY: I hereby authorize insurance payment directly to Integrated Orthopedics for medical services rendered. I understand that I am financially responsible for the charges not covered by my insurance. In the event of default, I promise to pay collection costs and reasonable fees as may be required to obtain collection of this account.* I AGREE Section E. – CIRCLE OF CARE RELEASEAuthorization to release health information via fax/phoneName, address, phone number, and fax number as applicableDates of Service from: Date Format: MM slash DD slash YYYY to: Date Date Format: MM slash DD slash YYYY Authorization Expires (unless otherwise noted this authorization will remain in effect one year from the date signed)Release the following information: All Records Chart Notes Radiology Operative Reports History & Physicals DECLINED Circle of Care Release Never I, hereby authorize the following as part of my circle of care, to discuss my treatment and/or release information to: Integrated Orthopedics | 20940 N. Tatum Blvd, Suite B290, Phoenix Arizona 85050 | Phone 602-734-1834 | Fax 602-734-1835 I AGREE Section F. – HIPPA REVIEW/AUTHORIZATIONI understand that: Once Integrated Orthopedics of Arizona discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of my health information. I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR (164.524). My records are confidential and cannot be disclosed without my written authorization except when otherwise permitted by law. The medical records to be released may include, but is not limited to: history, diagnosis, and/or treatment of drug or alcohol abuse, mental illness, or communicable diseases. This Authorization will remain in effect for one year or I provide a written notice of revocation to the Medical Record Department (45 CFR 164.508(c)(2)(i)).THIS AGREEMENT STATES THAT THE RESPONSIBLE PARTY AGREES TO TERMS STATED BELOW, We will bill primary and secondary insurances. You are responsible for deductible, coinsurance, copays, uncovered service, plus any supplies purchased and not covered by the insurance. If you are covered by Medicare, we will bill Medicare as your primary insurance. We will bill any secondary insurance also. You are responsible for deductible, coinsurance, copays, uncovered service, plus any supplies purchased and not covered by the insurance. You may be asked to sign an ABN (Advanced Benefit Notice) for services that are noncovered by Medicare. This financial agreement is based on information quoted by your insurance carrier via telephone, because your Insurance carrier may misquote your benefits to us, we strongly encourage all patients to verify their own benefit coverage, including co-pay amounts, remaining deductibles. THIS FINANCIAL AGREEMENT IS BASED ON BENEFITS QUOTED BY YOUR INSURANCE CARRIER AND IS EFFECTIVE THROUGH THE CALENDAR OR FISCAL YEAR, WHICH EVER CORRESPONDS TO YOUR INSURANCE POLICY. If reimbursement is to be received due to a personal injury, all adjustments are null and void and full balance without negotiation will be due at the time of settlement. All co-pays and co-insurance payments are due prior to treatment. We accept cash, check, or credit card. Should you be unable to keep a scheduled appointment, you must call at least 24 hours prior to your appointment. Patient’s, who fail to do so, will be charged a $35 fee. These charges will be the patient’s responsibility as insurance carriers will not pay for them. Your insurance coverage is an agreement between you (the patient) and your insurance carrier. Integrated Orthopedics will, as a courtesy, submit all eligible charges to your insurance carrier for payment. Please remember that you are ultimately financially responsible for all charges incurred during your course of treatment. A statement of charges showing patient responsible charges (those charges that are not covered by your insurance carrier) will be sent out monthly. A patient who has not patient responsible charges will not receive a statement until their course of treatment is completed. Upon completion of treatment, all patient’s will receive a statement showing all pending charges, adjustments and pending insurance payments. Any charges, which are the patient’s responsibility, are due immediately. If, after 90 days from your discharge date, we have not received payment in full from the Insurance Carrier, all outstanding charges will become the responsibility of the patient and are due immediately. We strongly encourage you to contact your insurance carrier, during this 90-day period, to check on the status of your claims. Please feel free to contact us if your insurance carrier needs additional information from us to process your claims. I understand that I am financially responsible for all charges incurred. Should this matter be turned over to our collection attorney all costs, including reasonable collection fees (35%-50%) and any court costs incurred by Integrated Orthopedics or our attorneys, shall be the responsibility of the patient or responsible party.Integrated Orthopedics 20940 N. Tatum Blvd., Suite B-290, Phoenix, AZ 85050- 602-734-1834 NOTICE TO PATIENTS State law, A.R.S. 32-1401 (25) (ff), requires that a physician notify a patient that the physician has a direct financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient and/or in the nonroutine goods or services being prescribed by the physician, and whether these are available elsewhere on a competitive basis. (I/We) support this law because it helps patients make reasoned financial decisions concerning their medical care. In compliance with the requirements of this law, you are being advised that (I/We) have a direct financial interest in the diagnostic or treatment agency or in the non-routine goods or services named below. Further, as indicated below, goods or services that (I/We) have prescribed are available elsewhere on a competitive basis. DIAGNOSTIC OR TREATMENT AGENCY OR NON-ROUTINE GOODS AND SERVICES: • SurgCenter at Pima Crossing • Insight Pharmacy • Trusted Care • Sanus DME, LLC. THESE SERVICES ARE AVAILABLE ELSEWHERE ON A COMPETITIVE BASIS: • Abrazo Hospital - Paradise Valley • John C. Lincoln North Mountain • Scottsdale Healthcare Thompson Peak • Honor Health Piper Surgery Center • Hanger • Summit Medical • American National DME • Scottsdale Medical Equipment and Supply The law provides for the acknowledgment of your having read and understood these disclosures by dating and signing this form in the spaces provided below.ACKNOWLEDGMENT: (I/We) have read this Notice to Patients, and (I/We) understand the disclosures that it contains.* I AGREE By signing below, I acknowledge that all information that I have provide is accurate to the best of my knowledge and that I understand that wherever I have checked "I AGREE" indicates that I accept the terms of that section.