1. finance
2. personal finance
3. insurance

Welcome to our office, and thank you for letting us take care of you!
PATIENT REGISTRATION FORM
(Please do not leave blank lines: place a hyphen (-) or N/A in any question that does not apply to you.
Primary Care Physician phone no:
Primary Care Physician:
Today’s Date:
INFORMATION
First:
Patient’s Last Name:
Middle:
Marital status:
Single
Is this your legal name?
Yes
Div
Birth Date:
(Former name):
If not, what is your legal name?
Mar
Sep
Wid
Sex:
Age:
M
No
F
Patient email address:
Can we communicate with you via email?
Yes
No
City:
Primary Street Address:
ID #:
Insurance carrier:
Are you the policy holder?
Alternative no:
Cell phone no:
Home phone no:
Social Security Number:
Yes
State:
Secondary/Supplemental carrier:
Effective Date:
Date of Birth:
Relationship:
No
ZIP Code:
Contact no:
Name of the policy holder:
Is this case (or will it be) involved in litigation?
Yes
No Date of injury: Adjuster or case Mgr name:
Phone no:
Is this case a Worker’s Compensation claim? (work related)
Yes
No
Fax no:
Were you referred here by Worker’s Compensation?
Yes
No
Chose clinic because/referred to clinic by:
Dr.
Insurance
Plan
Hospital
Pharmacy name and location:
Lawyer
Employer
Friend
Pharmacy phone no:
IN CASE OF EMERGENCY
Name of emergency contact:
Relationship:
Home phone no:
Work phone no:
I hereby authorize payment directly to Physicians for the Hand of all insurance benfits otherwise payable to me for services rendered. I understand that I am financially
responsible for all charges, whether or not paid by insurance, and for all services rendered for me or for my dependents. I authorize the doctors and/or any provider or
supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of my signature on all insurance submissions.
I authorize a copy of this document to be used in place of the original. I have read and agreed to the above.
Patient/Guardian signature
Date
Please answer to the following questions to the best of your ability.
List any allergies/reactions
Iodine
List all medications
None
None
Sulfur
Penicillin
Drug Allergy:
Shellfish
Food/
Environmental
Allergy:
Nuts
Pollen
Dust
Latex
Mold
History
No to all
Do you smoke?
No
Yes
How much?
Do you drink alcohol?
No
Yes
How often?
Do you get the shakes if you
go without drinking?
No
Yes
Do you use any other drugs?
No
Yes
Are you pregnant?
No
Yes
Unsure
Do you have (or have you had) any of the following medical conditions?
None
High Blood Pressure
Pneumonia
Stomach Ulcers
Migraines
High Cholesteral
Asthma
Blood Clots
Psychiatric
Osteopenia
Diabetes
Bronchitis
Phlebitis
Paralysis
Osteoporosis
Heart Attack
Emphysema
Urinary Tract Infection
Seizures
Spinal Stenosis
Irregular Heart Beat
Pulmonary Embolism
Birth Defect
Depression
Arthritis
Any other medical problem(s) not listed?
High Thyroid
Enlarged Prostate
Low Thyroid
Cancer:
HIV/AIDS
Radiation
Hepatitis
Blood transfusion?
Tuberculosis
No
Stroke
Rheumatoid Arthritis
Chemotherapy
Yes Reaction?
Previous Surgeries?
Tonsils
Thyroid
Appendix
Ear
Nose
Bowel
Stomach
Throat
Galt Bladder
None
Heart
Prostate
Cosmetic
Vascular
OB/Gym
Breast
Other
Orthopedic
Surgeries
Review of Systems: During the past 2 weeks, have you experienced any of the following?
Constitutional
Respiratory
Neurologic
Ear/Nose/Throat/Neck
Fevers
chills
Fatigue
Muscle aches
loss
Weight gain
Cough
Numbness
Painful urination
Nasal Congestion
Difficulty breathing
Weakness
Blood in urine
Bloody Nose
Wheezing
Headaches
Side/flank pain
Sore Throat
Chest pain when
taking a deep breath
Dizziness
Urine incontinence
Memory problem
Urinary frequency
Dental Problem
Cardiovascular
Gastrointestinal
pressure
Genitourinary
Hearing Loss
Loss of appetite
Chest pain
No to all listed.
Nausea
vomiting
Hormonal/Endocrine
Abnormal menses
Eyes
Pain
Musculoskletal
Neck
Muscle pain
Back
Heart skips a beat
Diarrhea
Hot Flashes
Discharge
Difficultly walking
Lightheadedness
Constipation
Dry Skin
Visual disturbance
Joint
Fainting
Excessive Sweating
Eyelid drooping
Stiffness
Abdominal Pain
Thin Hair
Stool Incontinence
Heat
Fainting
Leg Pain
Leg Swelling
Cramping
pain
Increased Thirst
appetite
Wrist
Hip
Foot (
swell
red
Deformity
Arm
Shoulder
Cold Intolerance
urgency
Elbow
Hand (
Thigh
Lt
Lt
Knee
Rt )
Rt )
Leg
Ankle
CHIEF COMPLAINT FOR TODAY’S VISIT
Location:
>Reason for today’s visit:
>Which is your dominant hand?
Left
Right
Both
Left
Right
Ambidextrous
>What date did the problem begin?
>How long have you had this problem?
Months
Years
Days
Briefly describe how the problem started.
Yes
No
>Are there any hobbies/activities you enjoy that this problem is keeping you from doing?
Car accident
Injured at work
Fall
>Please circle where you have pain or problem.
Medical Records pertaining to complaint.
Have you had any
testing(i.e. MRI,CT Scan,
X-Ray, Nerve Conduction,
etc.) for the problem.
None
Not treated by another physician
If you did not bring them please tell us where you went so we can obtain this information.
Yes
No
Name:
Address:
State:
City:
Did you bring your test
photos, CD, or results with
you today?
Yes
Have you been seen or
treated by another
physician for this problem?
Yes
No
Fax:
Phone:
Date of Test:
Name:
No
Address:
State:
City:
Did you bring your
medical records from this
office today?
Zip:
Fax:
Phone:
Yes
No
From:
Surgery:
Zip:
Until:
Date(if applicable);
Procedure done:
We are in the process of creating a newsletter for our patients with interesting health information. Would you be
No
Yes
interested in receiving this email?
The information I have given above is complete and accurate, to the best of my knowledge.
As will all medical records, the information that I have provided will be confidential.
x
x
Patient/Guardian signature
Date
Patient Financial Policy
Thank you for choosing Physicians for the Hand for your Orthopedic care. We sincerely hope that by
sharing our financial expectations we will strengthen the practice-patient relationship and keep the
lines of communication open.
General Information
Your insurance policy is a contract between you and your insurance company. You are responsible for
understanding the terms of your coverage and for any amounts not covered by your insurer.
• Referrals and/or authorizations are your responsibility: they must be obtained prior to your
office visit. Your appointment will be rescheduled if you do not have this information.
• It is your responsibility to resolve disputes between you and your insurance company regarding
deductibles, co-payments, covered charges, secondary insurance, and reporting of prior existing
condition information.
• Your balance is due within 30 days of receipt of a statement from us regardless of any dispute
with your insurance company.
• While our billing professionals will do all they can to help our patients in communication and
negotiating with their insurance plan, any question regarding coverage, benefits, or payment for
services provided is the patient’s responsibility to resolve.
• It is the patient’s responsibility to notify the office of any change of address, phone,
employment, or insurance coverage in a timely manner.
• We reserve the right to report delinquent accounts to credit bureaus, assess a collection fee,
take other collection action, or terminate you as a patient of this practice.
Payment is Due at the Time of Service
•
•
We accept cash, checks, and credit cards.
All co-payments, deductibles, co-insurances, and non-covered services are due at the time of
service.
Proof of Insurance
•
•
•
You must provide your insurance card and photo ID at each appointment.
We participate with most insurance plans. Please check with your insurer prior to your
appointment. We do not participate in any Medicaid insurance plan, nor do we file insurance in
the case of auto or liability insurance. These situations are handled under our Self-Pay policy.
It is your responsibility to provide complete insurance health insurance information. Claims
denied due to the failure to provide timely, accurate and complete insurance information are
your responsibility.
Self-Pay Accounts
•
•
•
Payment is expected at the time of service for Self-Pay accounts.
We will do our best to give patients an estimate of the charges in advance of the appointment.
This estimate is subject to change based on the treatment recommended and provided by the
physician and therapists.
A self-pay discount is offered when payment is made at the time of service. If you are unable to
pay in full at the time of service, please contact out Billing Office to make payment
arrangements.
Foreign Insurance
•
We file claims to insurers with claims addresses in the United States. Patients with insurers
outside of the United States are treated under the Self-Pay policy.
Occupational Therapy Services
•
•
•
•
We provide occupational therapy services in our offices. Insurers apply separate co-pays,
deductibles, and co-insurance to these services.
Often a key component of therapy services may include the fabrication of a custom splint for
you. Insurers consider splints fabrication as outpatient services (versus physician office) and
therefore your outpatient co-pay and/or co-insurance may apply.
Certain supplies used in our occupational therapy services are non-covered by insurance and
you will be responsible for the normal cost of the supplies.
We do our best to inform the patient in advance when these supplies are used in your care, but
the patient is ultimately financially responsible for services and supplies not covered by
insurance.
Medical Supply Charge
•
To save clerical and recover costs of miscellaneous medical supplies used in our practice, a fee
of $40.00 will be collected for each surgery and a fee of $10.00 for each office procedure. These
are for charges not covered by insurance carriers.
o
o
Procedures, including but not limited to:
 Cast application; Cast removal; Cast change; Suture removal; Injections
Partial list of materials not covered:
 Bandages, gauze, needles, syringes, lidocaine, clips, fasteners, sutures, scissors,
surgical trays
I have read the Patient Financial Policy and I agree to abide its terms
Patient Signature____________________________________Date:______________________
Patient Name:
____________________________________ Date of Birth:_______________
I have read the Privacy Policy and/or I have been given the opportunity to review it.
I agree that you may leave messages containing Protected Health Information on the following
numbers:
__________________________________________________________Home/cell/office/other
__________________________________________________________Home/cell/office/other
I agree that you may discuss my Protected Health Information with the following people:
_______________________________________Relationship____________________________
_______________________________________Relationship____________________________
_______________________________________Relationship____________________________
I understand that I can change these notifications anytime by given written notice.
Patient signature_____________________________________Date:______________________
Printed Name________________________________________Date:______________________
Medical Supply Charge
To save clerical and recover costs of miscellaneous medical supplies used in our practice, a fee of $40.00
will be collected for each surgery and a fee of $10.00 for each office procedure. These are for charges not
covered by insurance carriers.
Procedures, including but not limited to:
Cast applications; Cast removal; Cast change; Suture removal; Injections
Partial list of materials not covered:
Bandages, gauze, needles, syringes, lidocaine, clips, fasteners, sutures, scissors, surgical trays
Signature______________________________________________________
Occupational Therapy benefits notification
Physicians for the Hand offers Occupational Therapy
Patient Name:________________________________________________________________
Date:_________________________________________________________________
Occupational Therapy is a separate and identifiable service offered by this office.
Therapists are providers that are contracted separately from your physician.
Occupational Therapy has plan limits based on your insurance carrier.
There are separate co-pays for Occupational Therapy; Co-Pays are due at time of visit.
There are separate authorizations needed for youto your have your occupational therapy treatment at
our office. We obtain these authorizations for you. If you receive any questionnaires at home regarding
your treatment plan please fill them out and return to your insurance carrier; without that data
payment can be delayed and result in a bill to you.
If you are a surgery patient your Occupational Therapy visits are not part of the global treatment and are
not considered post op visits. Your first OT visit is customarily the day after surgery. At that visit the
bandage is charged and mobility is assessed. There is a charge for this visit as well as all subsequent
visits.
Some supplies and orthotics ordered by your physician may not be covered by your insurance plan. You
are responsible to make those payments.
Your health and wellness is our primary focus. By addressing the financial arrangements now we can
alleviate any concerns and allow you to focus on healing.
Payment arrangements can be made prior to treatment. Please ask to speak with the manager about
this option.
__________I will need to arrange for a payment plan.
__________I agree to the above and understand my responsibility in accordance with my insurance
carrier.
It is your responsibility to know and understand your insurance benefits.
Please contact your carrier if you have any questions regarding your policy or its limits and/or
exclusions.
Patient Signature:___________________________________________________________________
A. Notifier:
B. Patient Name:
C. Identification Number:
Advance Beneficiary Notice of Noncoverage (ABN)
NOTE: If Medicare doesn't pay for D.
below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have
good reason to think you need. We expect Medicare may not pay for the D.
below.
D.
E. Reason Medicare May Not Pay:
F. Estimated
Cost
A4550 - Surgical Tray
A6025 - Gel Sheets
Q4006 - cast supplies-fiberglass
Q4010 - cast supplies - gauze
A6441 - padding/bandage
A6457 - Tubular Dressing
Uncovered Charge
Uncovered Charges
Uncovered Charges
Uncovered Charges
Uncovered Charges
Uncovered Charges
$40.00
$36.00
$83.00
$55.00
$ 2.16
$ 3.69
WHAT YOU NEED TO DO NOW:
•Read this notice, so you can make an informed decision about your care.
•Ask us any questions that you may have after you finish reading.
•Choose an option below about whether to receive the D.
listed
Note: If you choose Option 1 or 2, we may help you to use any other insurance
that you might have, but Medicare cannot require us to do this.
G. Options: Check only one box. We cannot choose a box for you.
above.
OPTION 1. I want the D.
listed above. You may ask to be paid now, but I
also want Medicare billed for an official decision on payment, which is sent to me on a Medicare
Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for
payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare
does pay, you will refund any payments I made to you, less co-pays or deductibles.
OPTION 2. I want the D.
listed above, but do not bill Medicare. You may
ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.
listed above. I understand with this choice I
OPTION 3. I don't want the D.
am not responsible for payment, and I cannot appeal to see if Medicare would pay.
H. Additional Information:
This notice gives our opinion, not an official Medicare decision. If you have other questions on
this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You also receive a copy.
I. Signature:
J. Date:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7
minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-R-131 (03/11)
Form Approved OMB No. 0938-0566