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Transcript
9500 E IronScottsdale, A
Patient InName:
Address:
Phone: Ho
Birth Date
Employer
Employer ASpouse Na
Primary C
Emergenc
Relationsh
Who shou
ResponsibDo you havName of P
Relationsh
Insurance
Phone Nu
Do you ha
Name of I
SSN:_____
Insurance
If you areName of W
Employer
Date of In
Adjuster/
Carrier Ad
Patient In
nwood Sq Dr AZ 85258
nformation (c
(First)
ome ( )
e:
r (if Minor, Pa
Address: ame (if Minor
Care Physician
cy Contact:
hip to patient
uld we thank
le person if dve medical insPerson on acc
hip to Patient
e Company: __
umber of insu
ave additiona
Insured:
________ D
e Company: __
e covered undWorker’s Com
:
njury:
Case Manage
ddress:
itial:
Suite 125
confidential):
(M
SS#
arent’s Emplo
r, Parent’s Na
n:
t:
for referring y
different fromsurance covecount :
t:
___________
rance compa
al insurance?
OB:________
___________
der worker’s cmp or Motor V
er Phone No.:
iddle)
Work (__
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oyer)
ame)
you?
m above. rage: □
___________
any:________
□ Yes □ No
____
___________
compensatioVehicle Accid
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(Last
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SS# ‐
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Relation
_____ Policy N
n or motor vent Insurance
Claim No
uster/Case Ma
Patient
Phone: 480
t) City
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City
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ase complete
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ehicle insurae Carrier:
o.:
anager:
Registrat
0-626-2552 Fa
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Phone: (
Phone: (
Phone: (
Phone :
Birth Date:
_ Group Num
e the followin
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_ Group Num
nce, enter inf
tion Form
ax: 480-626-25
ate Zip
ate Zip
)
)
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mber:______
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mber:______
fo below:
m
551
_
_
_
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_
_
____
____
NEW PATIENT FORM
Patient Name : Age : M F
Name of Referring Physician :
Reason for Visit:
How long have you had this pain? Average Pain Level (1 (no pain) to 10 (worst) ) :
On the diagram below, mark the area where you have pain.
Name of PCP :
Mild
Constant
Aching
Burning
Pins/needles
Numbess
Moderate
Severe
Sharp/stabbing
Throbbing
Describe the pain
What makes your pain Worse:
What makes your pain Better:
Do you have WEAKNESS in your : Arms R L
Legs R L
Do you have NUMBNESS in your : Arms R L
Legs R L
Integrated Pain Consultants Page 1 of 4
TENS unit: Heat / Ice:
Chiropractor: Acupuncture:
Massage: Psychology:
Better Worse No Change
Better Worse No Change
Better Worse No Change
Better Worse No Change
Better Worse No Change
Better Worse No Change
TREATMENT HISTORY
For your current symptoms, please mark the boxes for the following imaging/studies that have been performed
Blood in urine………… Double vision…………… Seizures…………………
Skin ulcers………
Kidney problems …… Loss of vision…………… Dizziness………………..
Lumps………………
Yes No Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No
Are you CURRENTLY experiencing any of the following symptoms? If so, check mark Yes. Otherwise, check no (blank also implies no)
REVIEW OF SYSTEMS:
Patient/Representative Name (print) _________________________________________________
Signature___________________________
Date _____________________
Integrated Pain Consultants Page 4 of 4
AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
By signing below, I authorize INTEGRATED PAIN CONSULTANTS, its agents and employees (“Provider”), to use and/or disclose any and all of my Protected Health Information (“Records”) on my behalf, of any kind and description, to the following (“Recipient”):
I also allow my provider to release my protected health information to my insurance, primary care provider(s), referring provider(s), hospitals, diagnostic centers and/or laboratories that may require this information for continued care and authorize Provider to transmit this information through electronic means.
I understand that Recipient may redisclose the Records and that the Records may no longer be protected by the Federal privacy regulation.
I acknowledge and agree that the protected health information authorized to be disclosed under this Authorization may include records for drug or alcohol abuse or psychiatric illness, and records of testing, diagnoses or treatment for HIV, HIV-related diseases and communicable disease-related information. With respect to any communicable disease-related information protected by State confidentiality rules and disclosed under this Authorization, Recipient is prohibited from making any further disclosure of this information unless further disclosure is expressly permitted by me, pursuant to a separate written authorization, or is otherwise permitted by applicable law.
Patient Printed Name or Legal Representative: Date of Birth:
Patient or Legal Representative Signature: Date:
Recipient Name: Relationship:
Integrated Pain Consultants Last Revised Sept. 2016
Authorization to Disclose PHI including HIV Related information
Organized Health Care Arrangement/Data Exchange:Integrated Pain Consultants participates in an organized health care arrangement consisting of greater Phoenix metropolitan area hospitals, as well as physicians who have medical staff privileges at one or more of these hospitals. Participants in this arrangement work together to improve the quality and efficiency of the delivery of healthcare to their patients. As a participant in this arrangement, we may share your PHI with other members of this arrangement for purposes of treatment, payment, or the health care operations of this organized health care arrangement.
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HIPPA NOTICE OF PRIVACY PRACTICES
Uses and Disclosures of Your PHI: Treatment: Your PHI may be used to provide, coordinate, or manage your health care and any related services. We may also disclose your PHI to other health care providers who may be involved in your health care to ensure they have the proper information to diagnose, treat, as well as provide a service to you. Health Care Options: Integrated Pain Consultants may use and disclose your PHI to support the business activities of this office. Business activities include the following:
Evaluation of our staff directly or indirectly involved in your care Quality Assessment and Quality Improvement Information disclosed to physicians, nurse practitioners, physician assistants, nurses, paramedics, medical technicians, medical students,
and any other authorized personnel for educational purpose.We may disclose your PHI to a third party service, i.e. billing and transcription services, to perform certain activities. Furthermore, we may disclose a
limited data set of your PHI to a third party for certain business services. Payment: Payments obtained by us for health care services or to determine whether we may obtain payment for services recommended for you may require your PHI be used and disclosed. Your PHI may be disclosed to obtain payment or for payment activities from you, a health insurance plan, a healthcare clearinghouse, or a third party service.
Example: Information may need to be provided that identifies you, your diagnosis, as well as procedures performed, with a bill to your health plan to agree to payment for a treatment.
Appointment reminders/Treatment Alternative/Health Related Services: Your PHI may be disclosed by us to contact you, either by a staff member or automated system, to remind you of a scheduled medical appointment, treatment procedure, or with treatment alternatives, treatment options, or health related benefits and services which may be beneficial or of interest to you. Facility Directory: Unless objected by you, we may use and disclose in our facility directory, your name, location in the facility, general condition, and religious affiliation. All of this information, except for your religious denomination or affiliation, will be disclosed to persons who ask for you by name. Persons Involved in Your Care: Unless you object, we may use and disclose to a family member, relative, close friend, or individual you identify your PHI with, that is directly relevant to the person/s involvement in your care or payment related to your care. If you are unable to agree or object to a disclosure, we may disclose the information as necessary if we determine that it is in your best interest based on our professional judgment. Notificaton: Your PHI may be used or disclosed, by us, to notify or assist in notifying a family member, personal representative, or any person deemed responsible for your care of your location, your general condition, or death. Business Associates: Your PHI may be shared with other individuals or companies that perform various activities on behalf of our office. This activities may include, but are not limited to, after-hours telephone answering, quality assurance/quality improvement, or clinic research. Our business associates agree to protect the privacy of your information. As required by law:
Your PHI will be disclosed when required to do so by international, federal, state and/or local law. These may include public health activitieswhich include reporting certain communicable diseases, workers compensation or similar programs required by law, authorities when we suspect abuse, neglect, or domestic violence, health oversight agencies, including the Food and Drug Administration and Department ofHealth and Human Services, for certain judicial and administrative proceedings pursuant to an administrative officer, law enforcementpurposes and legal proceedings, medical examiner, coroner, or funeral director, the facilitation or organ, eye, or tissue donation if you are aregistered organ donor, to avert a serious threat to your health and safety of that or others, For governmental purposes such as militaryservice or for national security, in the event of an emergency for disaster relief, and inmates during the course of providing care.
Your PHI may be used for marketing and any purposes which require the sale of your information which require written authorization. Any other uses and disclosures not recorded in this notice will be made only with your written authorization which you may revoke at any time by submitting a written revocation and we will no longer disclose your PHI, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
IN THIS FORM YOU WILL LEARN HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION AND HOW YOU MAY OBTAIN ACCESS TO IT.
Integrated Pain Consultants (IPC) is dedicated to protecting your medical information. We are required by law to maintain the privacy of your protected health information (PHI) and to give you notice explaining our legal duties and privacy practices with regards to your PHI. We do reserve the right to change the terms of this notice and to
make the new notice effective for all PHI we maintain. Any revisions will be posted in our office, and upon request, a copy will be provided to you for your records.
HIPPA NOTICE OF PRIVACY PRACTICES
Inspect and Copy: You have the right to inspect and copy your PHI that we maintain about you for as long as we maintain that information. You may not inspect or copy psychotherapy notes; information compiled in reasonable anticipation of, or use in, civil, criminal, or administrative action or proceedings; or PHI that is subject to law that prohibits access to protected health information. In some circumstances, you may have a right to review our denial. If you wish to inspect or copy your medical information, you must submit your request in writing to the attention of our Privacy Officer at the address listed below. We may charge you a fee for the costs of copying, mailing or other supplies used in fulfilling your request. You may mail your request or bring it to the office. Integrated Pain Consultants has up to 30 days to make your PHI available to you, in which a fee may apply, or 60 days if stored offsite. Request an Electronic Copy: You have the right to request an electronic copy of your PHI be transmitted to you or your designated officer. We will make every effort to provide the electronic copy in the format your request, however, if it is not readily producible by us, we will provide it in either our standard format or in hard copy form but a fee may apply. Right to Receive Notice of a Breech: You have the right to be notified upon a breach of any of your unsecured PH and will be contacted in a timely manner. Request Restrictions: You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You may ask us not to use or disclose any part of your PHI, and by law, we must comply when the PHI pertains solely to healthcare items or services for which the health care provider involved has been paid out of pocket in full. Request must be made in writing to our Privacy Officer at the address below. If we agree to the restriction, we may be in violation of the restriction for emergency treatment purposes. By law, you may not request we restrict the disclosure of your PHI for treatment purposes. Request Amendments: If you feel the PHI we have is incorrect or incomplete, you may ask us to amend the information. A request and the reason for the requested amendment must be in writing to the Privacy Officer at the address below. In certain cases, we may deny your request. If we deny your request, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of the denial. Request Accounting of Disclosures: You have the right to request a list of our disclosures of you PHI, except for disclosures for treatment, payment, or health care operations; to you; incident to a use or disclosure set forth in this notice; to persons involved in your care; for notification purposes; for national security or intelligence purposes; to law enforcement officials; as part of a limited data set; that occurred before April 14, 2003, or six years from the date of the request. Your request must be in writing and must state the time period for the requested information. Your first request for a list of disclosures within a 12 month period will be free. If you request and additional list within 12 months of the first request, we may charge you a fee for the costs of providing the subsequent list. We will notify your of such costs and afford you the opportunity to withdraw your request before any costs are incurred. Request Restrictions: You have the right to request that we communicate with you only in certain ways to preserve your privacy. For example, you may request that we contact you by mail at a specific address or call you on a specific telephone number. You request may be made in writing with specific instructions on how and where we contact you. We will accommodate all reasonable requests and will not ask the reason or an explanation for your request.
If you have any questions about this notice or would like additional information, please contact our office at:
9500 E Ironwood Square Dr. Suite 125 Scottsdale, Arizona 85258
By signing below, I acknowledge that I have reviewed the HIPPA Notice of Privacy Practices of this office, which outlines how patient confidential information will be used, disclosed, and protected. I understand that I may refuse to sign this Acknowledgement.
Patent Printed Name or Legal Representative Date of Birth
Patient or Legal Representative Signature Date:
YOUR HEALTH RECORD IS THE PHYSICAL PROPERTY OF INTEGRATED PAIN CONSULTANTS. THE INFORMATION CONTAINED IN IT BELONGS TO YOU.
BELOW IS A LIST OF YOUR RIGHTS REGARDING INDIVIDUAL IDENTIFIABLE HEALTH INFORMATION. ALL REQUESTS RELATED TO THESE ITEMS MUST BE MADE IN WRITING TO OUR PROVACY OFFICER AT THE ADDRESS LISTED BELOW. WE WILL PROVIDE YOU WITH APPROPRIATE FORMS TOEXERCISE THESE RIGHTS. WE WILL NOTIFY YOU, IN WRITING,
IF FOR ANY REASON YOUR REQUESTS CANNOT BE GRANTED.
Please send the medical records at your earliest convenience.
Integrated Pain Consultants is authorized to furnish to I receive from:
I AUTHORIZE RELEASE OF THE FOLLOWING MEDICAL RECORDS:
o I GIVE PERMISSION TO RELEASE ALL MY MEDICAL RECORDS including information and records orcopies of records relating to the history, diagnosi s, treatment or services rendered to me inconnection with any condition or disease. This includes permission to release POTENTIALLYSENSITIVE INFORMATION which may include information concerning my treatment of mentalillness, Human Immunodeficiency Virus (HIV), alcoholism, drug use/dependency, venereal disease,sexual assaults, abortion, illegitimacy of birth , communications to social workers and/orpsychotherapies, psychologists, if any.
o I GIVE PERMISSION TO RELEASE ONLY RECORDS specifically described below:
I release I n t e g r a t e d P a i n C o n s u l t a n t s , and the Recipient/Discloser listed above, and any of their providers and staff from all responsibility or liability that may arise from this authorization. 1 may withdraw this authorization at any time by giving written notification to In tegrat ed Pa in Con su l tan t s , provided that I do so in writing and to the extent that you have already disclosed the information in reliance on this authorization.
Release Information to: Name - Integrated Pain Consultants Address – 9500 E Ironwood Sq Dr. Suite 125 Scottsdale, AZ 85258 Phone - 480-626-2552 Fax - 480-626-2551
Patient Signature (Parent's Representative if minor) Date
I understand that there is a $25 fee for all Personal record requests on paper plus shipping costs. By default, the past one year of records will be sent.
NAME:
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WILL NOT USE ANWITHOUT INFORMGREE TO CONTA
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E ANY PAIN MEDOR THIS VIA THEHIS RULE MAY L
AT IT IS MY RESPBE FILLED EARLY
AT THERE MAY BORY DEPRESSIO
WEIGHT GAIN ORHINERY AND FIN
E CONTINUOUS D SLEEP CHANGY CHANGES IN M
T TO FREQUENTAND COMPLIAN
E RISKS AND BENUDGEMENT ANWILL ENDANGER
AT SUDDEN STOURES AND OTHESS DECIDED JOIN
W MY PAIN PHYSI
EN I HAVE ANY CTORS, ASSISTANH ANY MEMBER
UNDERSTAND TE WILL RESULT ING PHYSICIANS.
GNATURE
MENT FOR CHR
INITIAL A
THIS AGREEMENTG FOR PAIN MAROLLED MEDICA
HE AGREEMENT,
TROLLED SUBSTAOR. IF I FEEL THAIBING DOCTOR.
NS WITH ANYON
DICATIONS FROME STATE OF ARIZEAD TO DISCHA
PONSIBILITY TO SY IF THEY ARE LO
BE RISKS THAT AN, BOWEL AND R LOSS, CHANGENE MOTOR MOV
USE OF PAIN MES. I ALSO UNDE
MY MENTAL STAT
T URINE TESTINGCE WITH RECOM
NEFITS OF TAKIND MOTOR SKILLSR MYSELF AND/O
PPING OF PAIN ER SYMPTOMS. NTLY BY MYSELF
CIAN TO REVIEW
CONTACT WITH TNTS, PHONE ANSOF THE OFFICE.
THE ABOVE INFON FORMAL DISCH
DATE:
RONIC PAIN ME
ALL SECT
T IS TO PREVENTNAGEMENT. THATIONS.
WE WILL STOP P
ANCES. I WILL NOAT ADJUSTMENS
NE NOR WILL I TA
M ANY OTHER DZONA PHARMACYRGE FROM THE
SAFEGUARD MYST, STOLEN, DES
ASSOCIATE WITHBLADDER DYSFUOF COORDINATEMENT) AND OT
