PATIENT INFORMATION SHEET Patient’s Name (Last, First, MI) Address (Street No.) City State Zip Cell Phone Home Phone Patient’s Employer Occupation Work Phone Sex M ___ F Marital Status Sgl______ Mar______ Div ____ Wid _ Oth Patient’s Birthdate MM DD YYYY Age Preferred Language Disabled Y ___ N Patient’s SSN Spouse’s Name & Employer Spouse’s SSN Who Referred You to Us? Who is your Primary Care Doctor? Person to notify in Emergency Relationship Phone # Person to notify in Emergency Relationship Phone # Responsible Party Name for Billing (if not the Patient) DOB Responsible Party SSN Relationship to Patient Spouse ____ Parent ____ Primary Insurance Policyholder’s Name DOB Sex M F Employer Phone # Insurance Company Policy # Group # Patient’s Relationship to Policyholder Self Spouse Child Secondary Insurance Policyholder’s Name DOB Sex M F Employer Phone # Insurance Company Policy # Group # Patient’s Relationship to Policyholder Self Spouse Child ETHNICITY & RACE (CIRCLE ONE) HISPANIC/LATINO AFRICAN AMERICAN/BLACK AMERICAN INDIAN ALASKA NATIVE CAUCASIAN/WHIT ASIAN OTHER MEDICARE INFORMATION STATEMENT TO PERMIT MEDICARE PAYMENT TO PROVIDER I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or it’s intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. Date: Signature: **SELF PAY PATIENTS SELF PAY PATIENTS ARE REQUIRED TO PAY A DEPOSIT OF $212.00 PRIOR TO BEING SEEN Date: Signature: WORKER’S COMPENSATION PATIENTS Date of injury: Has a claim been filed? Yes No Employer’s Name & Phone Number ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION I hereby authorize payment of the surgical and/or Medical Benefits, if any, otherwise payable to me, directly to the Physician for his services as described. I realize that I am responsible for payment for non-covered services. I also authorize the Physician to release any information acquired in the course of my treatment that is necessary to process insurance claims. DATE: SIGNATURE: W. Dickson Schaefer, M.D. Christopher J. Barnes, M.D. Daniel E. McBrayer, M.D. Kimberly A. Barrie, M.D. Toby L. Anderton, M.D. Michael E. Dilello, PA-C
Transcript
W. Dickson Schaefer, M.D. Christopher J. Barnes, M.D.
Daniel E. McBrayer, M.D. Robert J. Logel, M.D.
Michael E. Dilello, PA-C
$176.00
PATIENT INFORMATION SHEET
Patient’s Name (Last, First, MI) Address (Street No.)
City State Zip Cell Phone Home Phone
Patient’s Employer Occupation Work Phone
Sex
M ___ F
Marital Status
Sgl______ Mar______ Div ____
Wid _ Oth
Patient’s Birthdate
MM DD YYYY
Age Preferred Language
Disabled
Y ___ N
Patient’s SSN Spouse’s Name & Employer Spouse’s SSN
Who Referred You to Us? Who is your Primary Care Doctor?
Person to notify in Emergency Relationship Phone # Person to notify in Emergency Relationship Phone #
Responsible Party Name for Billing (if not the Patient) DOB Responsible Party SSN Relationship to Patient Spouse ____ Parent ____
Primary Insurance Policyholder’s Name DOB Sex
M F
Employer Phone #
Insurance Company Policy # Group # Patient’s Relationship to Policyholder
Self Spouse Child Secondary Insurance Policyholder’s Name DOB Sex
M F
Employer Phone #
Insurance Company Policy # Group # Patient’s Relationship to Policyholder
Self Spouse Child
ETHNICITY & RACE (CIRCLE ONE)
HISPANIC/LATINO
AFRICAN AMERICAN/BLACK
AMERICAN
INDIAN
ALASKA NATIVE
CAUCASIAN/WHIT
ASIAN
OTHER
MEDICARE INFORMATION STATEMENT TO PERMIT MEDICARE PAYMENT TO PROVIDER
I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or it’s intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me.
Date: Signature:
**SELF PAY PATIENTS SELF PAY PATIENTS ARE REQUIRED TO PAY A DEPOSIT OF $212.00 PRIOR TO BEING SEEN
Date: Signature:
WORKER’S COMPENSATION PATIENTS
Date of injury: Has a claim been filed? Yes No
Employer’s Name & Phone Number
ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION I hereby authorize payment of the surgical and/or Medical Benefits, if any, otherwise payable to me, directly to the Physician for his services as described. I realize that I am responsible for payment for non-covered services. I also authorize the Physician to release any information acquired in the course of my treatment that is necessary to process insurance claims.
DATE: SIGNATURE:
W. Dickson Schaefer, M.D.Christopher J. Barnes, M.D. Daniel E. McBrayer, M.D. Kimberly A. Barrie, M.D. Toby L. Anderton, M.D. Michael E. Dilello, PA-C
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NATIVE HAWAIIAN
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INDIAN
W. Dickson Schaefer, MD Christopher J. Barnes, MD Daniel E. McBrayer, MD
Kimberly A. Barrie, MD Toby L. Anderton, MD Michael E. Dilello, PA-C, ATC-L
Fayetteville Orthopaedics & Sports Medicine’s mission is to provide the region with outstanding orthopaedic health care in a personalized and professional manner. Our goal is to provide patients with the safest, most appropriate care through diagnosis, treatment, surgery, or other specialized service.
As a service to our patients, we will file insurance claims for each of your insurance policies. To assist with this service, we ask that you carefully and completely fill out our Patient Information and Medical Orthopaedic History Form.
We accept assignment of benefits form your insurance company. Patients are required to fulfill co-pay, co-insurance, and deductible obligations at the time your receive services.
Our financial services goal is to assist patients through individual attention and constructed mutual agreements between both parties for personal balance payments. We offer an extensive list of payment options:
• Cash or personalized check • Major credit cards, i.e. Visa and MasterCard • Partnering with CareCredit, healthcare financing • Assist Medicaid application process with Department of Social Services • Monthly payment plan centered on outstanding balance • Interest based preference
We understand there may be unexpected circumstances when you cannot pay at the time you receive services. Our billing staff is available to discuss and assist payment options.
Monthly payment plan minimums: • Balance < $500: $50 per month • Balance $500-$750: $75 per month • Balance $751-$1,200: $100 per month • Balance >$1,200: $150 per month
Patients with HRA (Health Reimbursement Account), HSA (Health Savings Account): • HRA-25% of allowable charge payable at time of service • HSA-100% of allowable charge payable at time of service
I acknowledge the immediate need to notify Fayetteville Orthopaedics & Sports Medicine of any changes or adjustments regarding my insurance information and understand the above Personal Financial Policy.
I have received a copy of the Fayetteville Orthopaedics & Sports Medicine’s Notice of Privacy Practices. I grant permission for Fayetteville Orthopaedics to send me email reminders, notices and other information.
Signature:_________________________________________________________________ I consent to disclosure of the following protected health information about me to the following family member(s) or person(s) involved in my care or payment for my care:
a. ______________________________ Relationship__________________ Phone_______________ b. ______________________________ Relationship__________________ Phone_______________
Check all that may apply: ¨ All my medical information ¨ Information necessary to schedule appointments for me ¨ Lab or test results ¨ Information necessary to provide, call in or pick up prescriptions for me ¨ Information necessary to help my family member(s) take care of me ¨ Information necessary to allow my family member(s) to pick up or arrange for medical equipment to be provided for me ¨ Information necessary to bill for or submit claims for care provided to me to government or private insurance payors
My consent will remain in effect as long as I am a patient of Fayetteville Orthopaedics & Sports Medicine unless and until I notify Fayetteville Orthopaedics in writing of any changes. __________________________________________ ___________________________________________ Signature of Patient or Representative Date __________________________________________ Print Name
1 Although allowed under HIPAA, North Carolina law does not permit release of PHI outside of the Hospital unless required by law, pursuant to a court order or patient authorization, or for treatment, payment, or health care operations purposes as defined and limited by HIPAA. There is no exception for family members except for residents of a nursing home. The North Carolina physician-patient privilege statute, N.C.G.S. § 8-53, and HIPAA allow verbal authorization or consent for release, respectively, of information to family members. However, the better practice is to document the patient’s consent in order to have clear evidence of the patient’s intent. The package does not include a consent or authorization to release PHI to other providers or to insurance companies or others since most providers already have such forms. The contents of this form can be combined with such existing consent forms.
W. Dickson Schaefer, MD Christopher J. Barnes, MD Daniel E. McBrayer, MD
Kimberly A. Barrie, MD Toby L. Anderton, MD Michael E. Dilello, PA-C, ATC-L
1. Refills may take 3 business days to process as providers/surgeons are not in clinic every day. Prescriptions may only be picked up by the patient or those listed on the Authorization for Use/Disclosure of Protected Health Information Form and with a valid identification.
2. Physicians and physician assistants will not refill prescriptions if you have not been seen within 90 days of your last visit.
3. You may request refills during normal business hours for any prescription, except for narcotics. After hours request for pain medications will be deferred to the next business day.
4. Take your medication as prescribed. Do not change the dosage or frequency of your medication without approval by your provider.
5. Only one pharmacy will be used for filling pain (narcotic) medications. You should notify us immediately if you must change pharmacies.
6. You are responsible for the security of your medications. Lost or stolen medications will not be replaced. Exceptions will only be made with a valid police report.
7. Depending on the medication and situation, a follow-up visit with your provider may be necessary before we can safely refill the prescription.
Pain Medications (Narcotics):
1. Orthopaedic Surgeons prescribe pain medications in the setting of an acute injury. Conditions such as broken bones, dislocations, and post-surgical care may require the use of a narcotic pain medicine to partially relieve your discomfort. Chronic conditions may require a referral to a pain management specialist to optimize your care.
2. These are controlled medications and have potential side-effects. These may include, but are not limited to: nausea, dizziness, itching, constipation, difficulty urinating, and difficulty breathing. You need to contact us if you experience concerning side effects of dial 911 if you are experiencing severe symptoms.
3. Pain medications are potentially addictive. Your provider may order extra blood, urine, or hair testing if indicated. Please alert us if you have concerns regarding addiction. Your provider can refer you to a specialist if necessary.
4. Your driving will be impaired if you are taking a pain medication and is not recommended. Similarly, we do not recommend the use of pain medications with heavy or potentially dangerous machinery operation such as lawnmowers, saws, or weapons of any kind.
5. Do not take pain medications with alcohol or illegal drugs. 6. Pain medications during pregnancy are inherently dangerous to the fetus or breast-feeding child. Please alert us so
that we can safely coordinate your care with your OB-GYN/Pediatrician. By signing below, you agree that you have read and understand this clinic’s policy regarding the prescription of medications:
1. It is illegal to alter a prescription in any way. Alteration of any prescription, or doctor’s note, may result in dismissal from our care and notification to the appropriate regulatory body (to include law enforcement).
2. You may not obtain pain medications from another provider without alerting our clinic promptly. This is unsafe and illegal. We must work with your other providers to ensure your safety.
3. Our staff/providers may check with your pharmacy and the NC Controlled Substance Reporting System to monitor prescriptions.
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