Patient Intake Form
Language
Contact Information
Contact Information
Emergency Contact
Emergency Contact
Insurance Information
Insurance Information
Spouse Information
Spouse Information
Primary Care Physician Information
Primary Care Physician Information
Referring Physician Information
Referring Physician Information
Workers Compensation and Auto
Workers Compensation and Auto
If YES, please provide the following:
Pain Management
Pain Management
Please complete WC Form
If YES, please provide the following:
For Minors / Legal Guardian
For Minors / Legal Guardian
PLEASE FILL THIS PORTION OUT IF PATIENT IS A MINOR OR HAS A LEGAL GUARDIAN:
Pharmacy Information
Pharmacy Information
Medications
Medications
Allergies
Allergies
Family History
Family History
Mother
Father
Grandparent
Medical Problems/ History
Medical Problems/ History
Check all that apply
Social History
Social History
Check all that apply
Do you live in a:
Surgical History
Surgical History
Check all that apply
Injury Information/ Reason for Today’s Visit
Injury Information/ Reason for Today’s Visit
Musculoskeletal Review of Symptoms
Musculoskeletal Review of Symptoms
Current Medical Status
Current Medical Status
Check ONLY what applies
Body Parts Involved
Body Parts Involved
Check ONLY what applies
Which of the following, if any, makes symptoms worse?
Do you have any of the following?
Previous treatment for this problem?
Consent to Treatment and Payment Authorization
Consent to Treatment and Payment Authorization
I hereby give my consent to the physicians and other clinical personnel of for Sports Medicine & Joint Replacement Specialists, Corp. for the evaluation and treatment of the conditions for which I present in their offices.
I hereby authorize the office of Sports Medicine & Joint Replacement Specialists, Corp. to release any medical information required to permit payment directly to them for services rendered.
I authorize Sports Medicine & Joint Replacement Specialists, Corp. to release information related to my condition to the applicable worker's compensation carrier, auto insurance carrier, or my personal health insurance carriers as necessary based on the type and place of injury.
I recognize and accept the responsibility for services rendered regardless of insurance coverage; including but is not limited to, co-insurance, co-payment, deductible, and non-covered services.
Sports Medicine & Joint Replacement Specialists Corp. will not accept any attorney's letter of protection. All charges for my care are ultimately my responsibility to pay in full, within 60 days of services rendered.
Patient Consent for Use and Disclosure of Protected Health Information
Patient Consent for Use and Disclosure of Protected Health Information
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement.
The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication.
You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treatment upon execution of this consent.
Please sign your name in the area below