Allied Bone and Joint

6301 University Commons, Suite 100 2349 Lake Ave, Suite 201

South Bend, IN 46635 Plymouth, IN 46563 574-247-4667 • Fax 574-571-4458 574-540-2500 • Fax 574-540-2570

PATIENT INFORMATION

Name_______________________________________________Nickname__________________________

Last First Middle initial (if applicable)

SS # ______-______-______ Date of Birth_____________ Age_______ Sex Male Female

Address_____________________________________City________________State_____ Zip__________

Phone Number______________________Cell_______________________Work:____________________

Email Address:__________________________________________________________________________

Preferred Contact: Home Cell Work Email Religious Beliefs: ________________________

Marital Status: Married Single Divorced Separated Widowed

Primary Language: English or Other___________ Race:________________ Ethnicity:_____________

Patient Employer:__________________________________Occupation:____________________________

Is your injury work or auto related? YES/ NO (****if yes please see back of form****)

Family physician:_____________________________ Referring Physician :___________________________

How did you hear about us? Internet /Insurance Co. /Television /Phone book /Hospital/ Other______________

Emergency

Contact______________________Phone_(____)________________Relationship____________________

PRIMARY INSURANCE/ADDITIONAL INSURANCE

Name of Policy Holder__________________________________________Date of Birth_______________

Social Security #______-_____-_____ Relationship to Patient____________________________________

Address (if different from patients)__________________________City__________State______Zip______

Insurance Co.________________________________ID#_______________________Group#___________

Is patient covered by additional insurance? Yes /No

Name of Policy Holder__________________________________________Date of Birth_______________

Social Security #______-_____-_____ Relationship to Patient____________________________________

Address (if different from patients)__________________________City__________State______Zip______

Insurance Co.________________________________ID#_______________________Group#___________

Parent(s) /Guardian Information

(If patient is a minor)

Name_________________________________________________Relationship______________________

First Middle Last

Address___________________________________City__________________Sate______Zip___________

Social Security #_______-______-______ Date of Birth ______/_______/_______

Workman’s Compensation/Liability

(please complete if work or auto related)

Workman’s Comp/Liability Carrier_________________________________________________________

Billing Address______________________________City__________________State________Zip_______

Contact Person______________________________Claim #___________________Date of injury_______

Contact Phone #_(_____)______________________Contact Fax #_(____)__________________________

Notice to Our Patients

As required by the HIPAA Privacy Regulations, all patients who received health care service in our office must:

Receive the attached “Notice of Privacy Practices” form; and

Sign the “Acknowledgement” form below.

A complete list of this policy is available in our office at your request.

Please note that the attached notices are not a consent form. This form must be read in full by the patient and signed before treatment can

be provided; rather, the Notice provides each patient with a summary description of: How our office will use and disclose their medical information for legitimate business purposes.

How each patient can exercise their rights with regard to this medical information.

IN ORDER FOR US TO REMAIN HIPAA COMPLIANT PLEASE LIST ANY PERSON(S) OR COMPANIES THAT YOU GIVE

YOUR PERMISSION TO OBTAIN WRITTEN OR VERBAL INFORMATION ON YOUR BEHALF: (DO NOT LIST

YOURSELF OR OTHER PHYSICIANS)

_____________________________________________________________________________________________________ Name Relationship Phone Number

_____________________________________________________________________________________________________ Name Relationship Phone Number

IONS Policies and Procedures

You must allow five to seven business days for completion of all forms. There will be a minimal charge per form. If you need the form filled

out immediately there will be an additional per form charge.

Please allow 24 hours for medication refills to be called in. Medication refill requests must be made during business hours only.

A fee may be assessed to the account if proper cancellation notice is not given. You may be discharged from the practice after 4 missed appointments. New patients will be discharged after 2 missed appointments.

Assignment and Release

I certify that I, and/or my dependant(s) have insurance coverage with the above named insurance companies and assign directly to Allied Bone and Joint all insurance if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges

whether or not paid by insurance. I authorize the use of my signature on all insurance admissions. The above named office may use my health

care information and may disclose such information to the above named Insurance Company (ies) and agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current

treatment plan is completed or one year from the date signed below. I acknowledge that I have received a current copy of the Privacy Notice. I

also authorize the above practice or any outside agency to contact me regarding my patient balance. I understand and agree to receive artificial or pre-recorded voice or auto-dialed calls to designated cellular or residential telephone numbers for the purposes of debt collection or other

purposes. I also acknowledge that I have read and understand all other policies and agree to the terms set above.

X_______________________________________________________________ ___________________________

Signature of patient/guardian/personal representative Date

Allied Bone and Joint Medical History Form

Patient Name: _____________________________________________DOB:_ ___/____/____ Age: _______ Height: ________ Weight: ________

Primary Care Physician: _______________________ Referring Physician: _____________________ Pain Management: __________________

Allergies: __________________________________________ Reaction: ______________________________________________________

___________________________________________________ _______________________________________________________________

Medications: Please list prescription & Over the counter medications: ________________________________________________________

______________________________________ _________________________________________ _____________________________________

______________________________________ _________________________________________ _____________________________________

Preferred Pharmacy: (please list name and intersection of pharmacy) ____________________________________________________________

Patient Past Medical History: PLEASE CHECK ALL THAT APPLY TO YOU OR □ N/A

□ Asthma □ Aids/HIV □Alcoholism □Allergies □Alzheimer’s Dementia □Blood Disease

□Cancer □COPD □Depression □Diabetes □Heart disease □Hepatitis

□Migraines □Obesity □Osteoarthritis □Osteoporosis □Renal/Kidney Disease □Seizure Disorder

□Stroke □Hypertension (high blood pressure) □Other_____________________________________________________

Chief Complaint: What body part are we seeing you for? LEFT or RIGHT _________________________________________________________

Have you received treatment of any kind for this condition; if so what?: __________________________________________________________

Was this work related? YES / NO Was this due to a motor vehicle accident? YES / NO Date of Onset / Injury: _________________

How/Where did you get hurt? _______________________________________________________________________________________________

Have you had any X-rays, MRI’s or CT’s related to the above problem? Yes / No Where?____________________________________________

Please rate your pain at its BEST Please rate your pain at its WORST on a scale of 0-10 (0=NO pain, 10=Extreme pain): on a scale of 0-10 (0=NO pain, 10=Extreme pain):

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10

Circle the word(s) that best describe your pain:

Radiating / Aching / Burning / Dull / Piercing / Sharp / Throbbing / Other________________________________________________________

What makes your pain WORSE?: Bending / Stairs / Lifting / Movement / Pushing / Sitting / Standing / Walking /

Other__________________________________________

What makes your pain BETTER?: Brace / Elevation / Exercise / Heat / Ice / Massage / Medication(s) / Movement / Therapy / Rest /

Stretching / Other_____________________________

BP______/______

P______________

O2 Sat_________

Do you have any of the following associated with what we are seeing you for:

Bruising / Crepitus / Decreased Movement / Difficulty Sleeping / Instability /Limping / Locking / Night Pain / Popping/ Spasms / Swelling /

Tingling /Tenderness / Weakness / Numbness / Other: ____________________________________________________________________________

Patient Review of Systems: please check all that apply to you currently:

Constitutional

□Good general health

□Fatigue

□Fever

□Night Sweats

□Weight Gain

□Weight Loss

Cardiovascular

□Chest Pain/Angina

□Irregular Heartbeat

□Leg Swelling

□Syncope

Genitourinary

□Dysuria (Painful)

□Frequent Urination

□Hematuria (Blood)

□Urinary Incontinence

Metabolic/Endocrine

□Cold Intolerant

□Hair loss

□Heat Intolerant

HEENT

□Headache

□Hearing Loss

□Vertigo (dizziness)

□Vision Loss/Glasses /Contacts

Gastrointestinal

□Abdominal Pain

□Constipation

□Diarrhea

□Nausea/Vomiting

Neurological

□Difficulty walking

□Dizziness

□Poor Coordination

□Paresthesia (numbness)

□Tremors

Respiratory

□ Cough

□Dyspnea(shortness of breath)

□ Wheezing

□ Recent Infection

Psychiatric

□Anxiety

□Depression

□Insomnia

Integumentary

□Itchy Skin

□Rash/ Skin disorder

Hematologic

□ Blood Disorder

□Clotting disorder

Other:

Past Surgical History: Please list any surgeries OR □ N/A: ________________ ___________________________________

___________________________ _____________________________ _________________________ _____________________

Family History: Has your mother, father, sister or brother had any of the following: OR □ N/A

□Hypertension □Asthma □AIDS/HIV □Alcoholism □Allergies □Alzheimer’s/Dementia □Blood disease

□Hepatitis □COPD □Cancer □Depression □Diabetes □Heart Disease □Migraines

□Obesity □Osteoarthritis □Osteoporosis □Renal/Kidney Disease □Seizure Disorder □Stroke

□Other_______________________________________________________________________________________________

Social History:

Occupation: _______________________________________________ Student

Tobacco Use? YES NO Type/how much? _____________________________Year Quit? / Years smoked?_______

Substance Abuse? YES NO Substance: __________________________________ Year Quit? ______________

Alcohol Consumption? YES NO How many drinks per week? ________________________

Caffiene Use? YES NO what type: ________________________________________ Amount Daily?:__________

Bone Health:

Have you ever had a bone density test? YES / NO

If yes, where?:_______________________________________

If no, are you interested in an osteoporosis screening? YES / NO

Patient or Guardian Signature: ___________________________________________ Date: ______________

Physician Review: ______________________________________

Discrimination is Against the Law. Allied Physicians of Michiana complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Allied Physicians of Michiana does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Allied Physicians of Michiana:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters Written information in other formats (large print, audio, accessible

electronic formats, other formats) Provides free language services to people whose primary language is not

English, such as: Qualified interpreters Information written in other languages

If you need these services, please let us know. If you believe that Allied Physicians of Michiana has failed to provide these services or discriminated in another

way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with : Allied’s

Human Resources Generalist, 6301 University Commons, Suite 230, South Bend, IN 46635, office: (574)251-

2106, fax: (574)251-1339, compliance@apom.com. You can file a grievance in person or by mail, fax, or email.

If you need help filing a grievance, our Human Resources Generalist is available to help you. You can also file a

civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electroni-

cally through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/

lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue,

SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms

are available at http://www.hhs.gov/ocr/office/file/index.html.

NOTICE OF NON-DISCRIMINATION

Discrimination is Against the Law. Allied Physicians of Michiana complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Allied Physicians of Michiana does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Allied Physicians of Michiana:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters Written information in other formats (large print, audio, accessible

electronic formats, other formats) Provides free language services to people whose primary language is not

English, such as: Qualified interpreters Information written in other languages

If you need these services, please let us know. If you believe that Allied Physicians of Michiana has failed to provide these services or discriminated in another

way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with : Allied’s

Human Resources Generalist, 6301 University Commons, Suite 230, South Bend, IN 46635, office: (574)251-

2106, fax: (574)251-1339, compliance@apom.com. You can file a grievance in person or by mail, fax, or email.

If you need help filing a grievance, our Human Resources Generalist is available to help you. You can also file a

civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electroni-

cally through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/

lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue,

SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms

are available at http://www.hhs.gov/ocr/office/file/index.html.

NOTICE OF NON-DISCRIMINATION

ATTENTION: If you speak a foreign language, language assistance services, free of

charge, are available to you. Call 574-247-4667

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Pennsylvania Dutch: Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: 1-574-247-4667. French: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-574-247-4667.

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Hindi:

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-574-247-

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Tagalog: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang wa-lang bayad. Tumawag sa 1-574-247-4667. Panjabi: Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-574-247-4667. Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-574-247-4667. Burmese:

1-574-247-4667

1-574-247-4667

1-574-247-4667