Thank you for scheduling an appointment with one of our physicians. It is our pleasure to welcome you to the Department of Orthopaedic Surgery and Sports Medicine in advance of your first visit. Downtown: The Orthopaedic Clinic is located at Two Medical Park, Lower Level, Suite L9/ L10. The Sports Medicine Clinic is located at Two Medical Park, Suite 104. Parkridge: The Parkridge Clinic is located at 300 Parkridge Drive, Suite 201, Columbia, SC 29212 Below are important items you need to look over prior to your first visit to our practice. Some require action on your part. Insurance Coverage: Please bring your insurance card to your scheduled appointment. Without verification of your insurance coverage your appointment may be rescheduled, or you will be expected to pay all fees at the time services are rendered. If your insurance carrier requires referral authorizations, it is your responsibility to check with your primary care physician to ensure they have authorized your visits to our office. Without this authorization you will be expected to pay for the services you receive, on the date of your appointment, in full. Medical Information: Please have your medical records forwarded to us prior to your appointment. We need to review these records which may include x-rays, MRI’s, bone scans, and notes of visits to other physicians. Please bring with you all medications you are currently taking so we can accurately document this information in your patient chart. Medical History Forms: Attached you will find medical history forms that will need to be completed prior to your visit at our office. These forms, completed in entirety, are required in our office prior to being seen by any of our physicians. You may either bring the completed forms with you on the day of your appointment or mail them if time allows. Minors under the Age of 18: Patients that are under the age of 18 must be accompanied by a parent/legal guardian. If a parent/legal guardian is unavailable to attend the visit, the form Consent to Medical Treatment and Responsibility for Medical Charges for Minors must be filled out and given at time of check in. Cancellation Policy: Patients will be accessed a $25 fee for all appointments not cancelled 24 hours in advance. No Show Policy: Patients that miss over 3 scheduled appointments in one calendar year will not be allowed to schedule another appointment. Any of the above information that is missing on the day of your scheduled appointment may cause a reschedule of your appointment. We encourage you to arrive 30 minutes prior to your scheduled appointment time. If you have any questions prior to your visit, please contact our office by calling 803-434-6812. kjh 5-26-15 DEPARTMENT OF ORTHOPAEDIC SURGERY 803-434-6812, FAX 803-434-7306 www.uscortho.com/www.uscsportsmedicine.com Please Print Clearly – Thank You! DATE PATIENT INFORMATION First Name Middle Initial Last Name Street Address City State Zip Mailing Address City State Zip Email Address Employer/School_ Occupation Employer Address City Home Phone # Date of Birth State Work Phone # Zip Cell Phone # Social Security #_ Driver’s License # Nearest relative not living with you: Phone # Primary Care Physician: Referred to this office by: Preferred Pharmacy (name and address): PRIMARY INSURANCE Policy #_ Group # Insured’s Name Relationship to Patient Insured’s Social Security # or ID # Insured’s DOB Insurance Co. Name Insurance Co. Phone # Insurance Co. Address City State Zip SECONDARY INSURANCE Policy #_ Group # Insured’s Name Relationship to Patient Insured’s Social Security # or ID # Insured’s DOB Insurance Co. Name Insurance Co. Address Insurance Co. Phone # City State Zip DEPARTMENT OF ORTHOPAEDIC SURGERY 803-434-6812, FAX 803-434-7306 www.uscortho.com/www.uscsportsmedicine.com revised 5.26.15 Name:_ MRN: DOB: / / Visit Information Reason for visit: Referring Physician: Date of Injury: Primary Care Physician: Type of Pain: Stabbing Ache Severity: None 0 1 2 3 4 5 6 7 8 9 10 (10=Worst Pain) Previous Tests: X-ray CT Pain Aggravated By: Standing Sleeping Sitting Walking Working Driving Lying Stairs Throbbing Shooting Duration of Pain: / Dull Site of Pain (mark on images) Front Back / Click/Pop R MRI Location of Test: Treatments Attempted: Anti-inflammatory Pain Medications Injection Physical Therapy Surgery Splint/Boot/Brace L L R Rest Ice NONE Please Explain your current problem, in detail. Include location of problem, symptoms, how long you have experienced those symptoms, and the severity of them. Include what makes problem worse or better. Current Health Seizures Liver Disease/Jaundice Osteo Arthritis/Gout Chronic Headache Infections: Please Explain: Other Illness: Please Explain: Please list any health problems that you are currently diagnosed with: Lung Disease High Blood Pressure Thyroid Problems Stomach Ulcers Heart Disease Cancer Kidney Disease Asthma Diabetes HIV/AIDS Depression High Cholesterol Pulmonary Embolism DVT (Blood Clots) Rheumatoid Arthritis Hepatitis C Height: Weight: Surgical History Please list any previous surgeries and approximate dates of surgery: Surgery: Known Allergies to Anesthesia: No Date: / / / / / / / / Yes Surgery: Describe: NONE Date: / / / / / / / / Medications Please list any medications that you currently use, including over-the-counter medications, vitamins, herbs, and prescribed drugs. Medication: Dose: Medication: Department of Orthopaedic Surgery NONE Dose: Please Turn Over Allergies Known Drug Allergies: NONE Latex Penicillin Acetaminophen Sulfa Drugs Other: Morphine Ibuprofen Diagnostic Dyes Aspirin Iodine Codeine Family History Problem: Diabetes: Heart Disease: Asthma: Other: Does it run in your family? No No No No Please list family member (s) who have had this health issue. Yes Yes Yes Yes No No No Arthritis: Blood Clots: Cancer: Yes Yes Yes Social History Occupation: Current: Past : Do you live alone: Do you smoke? Do you drink alcohol? Any substance abuse? Disabled Retired Yes Yes Yes Yes No No No No With whom? How many packs per day? Type: Frequency Please List: Reason for Disability: Daily Quit? Weekly Months ago Monthly Yearly Years ago Review of Systems: Yes/No Check yes if applicable. Yes/No Weight Loss Chills Fever Decreased Appetite Blurred Vision Glasses Contacts Vision Loss Hearing Loss Sore Dentures Heart Attack Aortic Aneurysm Palpitations Leg Swelling Heart Murmur Shortness of Breath Sleep Apnea Wheezing Pneumonia Productive Coughing Bladder Infections Blood in Urine Burning When Voiding Other: MD Only: All other systems reviewed and found to be negative Yes/No Yes/No Incontinence Hemorrhoids Kidney Stones Injury Joint pain Muscle Pain Swelling Easy Bruising Rash Dizziness Tingling Fainting Bad Balance/Falling Stroke Trouble with Memory Edema Anemia Bleeding Disorders Blood Clots Sexually Transmitted Disease Anxiety Sleep Disturbances Numbness Headaches Signature Signatures Patient Signature: Date: Department of Orthopaedic Surgery / / Authorization Regarding Payment and Release of Medical Information Patient’s Name: Chart #: I hereby authorize and request the payment of services from Medicare, Medicaid and/or other insurance plans or payors be made on my behalf to University Specialty Clinics – Department of Orthopaedics. I hereby assign to University Specialty Clinics – Department of Orthopaedics all payments for treatment services. I hereby allow University Specialty Clinics to file an appeal for me with Medicare, Medicaid and/or other insurance plans or payors for any reason. I understand and agree that I am responsible for paying any amount not covered by Medicare, Medicaid and/or other insurance plans or payers. (PLEASE READ THE ATTACHED FINANCIAL AND INSURANCE POLICY FOR OUR PRACTICE) I hereby authorize the release of medical information to Medicare, Medicaid and/or insurance plans or other payers. I also authorize the release of medical information to other healthcare providers including, but not limited to, my primary care or family physician, consulting physicians or healthcare providers, hospitals, rehabilitation center, or other healthcare providers or facilities. I authorize my healthcare providers to review my prescription history from my pharmacist(s) for purposes of treatment. I permit a copy of this authorization to be used. Patient’s/Patient’s representative’s Signature Witness Signature Date Date Printed patient’s or Representative’s Name Representative’s relationship to Patient Consent to Treatment I hereby agree to and give consent to the physicians, healthcare providers, associates, and consultants of University Specialty Clinics – Department of Orthopaedics , and residents of affiliated institution, Palmetto Health, to diagnose and treat me. I consent to any and all treatment including, but not limited to, physical examinations, psychological examinations, x-rays, laboratory procedures, and other procedures related to routine diagnosis and treatment as determined appropriate by the practice’s physicians, healthcare providers, associates, consultants and residents. I give permission to share my electronic medical record among my healthcare providers and obtain medication history through a Provider Health Information Exchange (HIE). The University Specialty Clinics will abide by state and federal law regarding the availability to and access by the other medical providers of any sensitive information, such as behavioral health, substance abuse treatment, sexual abuse, genetic test results, HIV/AIDS status and adoption records. I MAY OPT OUT OF THE HIE BY COMPLETING THE OPT- OUT FORM AND CONTINUE TO RECEIVE CARE. Patient’s/Patient’s representative’s Signature Witness Signature Date Date Printed patient’s or Representative’s Name Representative’s relationship to Patient Authorization to Release Information to Coach or Athletic Trainer I authorize the release of medical information to the coach or athletic trainer of the school/athletic organization listed below for the purpose of providing the best comprehensive care. I may revoke this authorization at any time. Such revocation must be in writing and delivered to University Specialty Clinics. The revocation will not apply to records and information that have already been disclosed. School/Athletic Club Rev 3-4-15 If under age 18, Parent or Legal Guardian’s Department of Orthopaedic Surgery Two Medical Park, Suite 404, Columbia, SC 803-434-6812 Signature Date University Specialty Clinics Notice of Privacy Practices By signing below, I state that I have been given my own copy of the University Specialty Clinics’ Notice of Privacy Practices, effective date August 1, 2013. Printed Name of Patient Signature of Patient Date OR Printed Name of Patient’s Representative Signature of Patient’s Representative’s Date Description of Authority to Act on Behalf of Patient Effective Date 11/27/2013 Department of Orthopaedic Surgery Two Medical Park, Suite 404, Columbia, SC 803-434-6812
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