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PATIENT REGISTRATION FORM

PATIENT INFORMATION


PATIENT INFORMATION

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INSURANCE INFORMATION


INSURANCE INFORMATION

PRIMARY INSURANCE
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SECONDARY INSURANCE (if applicable)
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IN CASE OF EMERGENCY


IN CASE OF EMERGENCY

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INSURANCE AUTHORIZATION


INSURANCE AUTHORIZATION

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NEW PATIENT INFORMATION


NEW PATIENT INFORMATION

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What is the status of your claim?
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Have you had any of the following treatments for your pain?
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PAST MEDICAL HISTORY: (Personal and Family)


PAST MEDICAL HISTORY: (Personal and Family)

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QUESTIONNAIRE: Please indicate all that apply


QUESTIONNAIRE: Please indicate all that apply

FAMILY HISTORY OF SUBSTANCE ABUSE
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PERSONAL HISTORY OF SUBSTANCE ABUSE
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ALLERGIES: Please check all that apply


ALLERGIES: Please check all that apply

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CURRENT MEDICATIONS


CURRENT MEDICATIONS

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SURGICAL HISTORY


SURGICAL HISTORY

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PHARMACY INFORMATION


PHARMACY INFORMATION

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REVIEW OF SYSTEMS: Please select all that apply


REVIEW OF SYSTEMS: Please select all that apply

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SOCIAL HISTORY


SOCIAL HISTORY

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If yes, please answer these following questions
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PAIN DIAGRAM


PAIN DIAGRAM

Pain Diagram

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FUNCTION AND PAIN ASSESSMENT


FUNCTION AND PAIN ASSESSMENT

Evaluation of current pain interference-- this scale’s examples of activities at different levels are not meant to be exclusive. In the last month, how much has pain interfered with the worker’s daily activities and functions? Check number:*
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PRACTICE POLICIES


PRACTICE POLICIES

In an effort to best meet the needs of all of our patients, we would like to remind everyone of the following policies. Thank you.

1. APPOINTMENT CONFIRMATION/CANCELLATION POLICY 

As a courtesy, you will receive a COMPUTER call 2 days prior to your appointment to remind you of the date and time. Please follow the computer prompts to confirm. If you would like to cancel, please contact our office at least one business day PRIOR to your appointment. *Effective November 2008, there will be a patient charge of $25 for any appointment not cancelled with at least a 1 business day notice

2. MEDICATION PRESCRIPTIONS

All medication prescriptions will be given during your scheduled appointment time. These prescriptions will be for the amounts appropriate to control your pain until your next visit and must be utilized as directed by your provider. Early refills are only allowed with authorization by the prescribing physician. Refills requests cannot be given over the phone. You are responsible for your prescriptions. Stolen or lost refills will not be replaced until the date for which they were originally scheduled. We do not prescribe medication for undiagnosed pain. You must inform us of any prescription controlled substances you are obtaining through other physicians. Failure to do so may result in discharge from our practice. It is illegal to share prescription drugs and to alter or forge prescriptions, and our practice reserves the right to discharge patients engaging in such activities. Our practice also reserves the right to discharge patients engaging in activities considered “drug-seeking”, such as persistent medication use past the period indicated by the physician; repeated visits to emergency rooms with pain complaints; and other activities in this category, at the discretion of your provider.

3. CLINICAL QUESTIONS

If you have questions, would like to leave a patient update or request information you can contact us via the WEB PORTAL. Please visit www.thephysicians.com and select PATIENT PORTAL. However, if the question requires extensive medical decision making, you will need to schedule an appointment.

4. FORMS AND ADDITIONAL REQUESTED SERVICES

There will be a processing fee for completing insurance and disability forms not directly associated to billing your visits. The fee will be determined by the physician, depending on the extent required of the form. This fee also applies to the insurance medication prior approval process, which your insurance carrier does not include in your physician services. We appreciate your understanding with these policies. We unfortunately cannot control the additional work insurance companies are requesting for patients and providers each year that are not included in the medical services provided. We are doing our best to make sure that we remained focused on the services we provide –medical care- in order to treat our patients with the highest level of care possible.

5. MEDICAL RECORDS

Please note that any requests for medical records copies needs to be in writing. We will fax records directly to your other treating providers, upon this written request, for no fee. Appropriate copying charges will apply for all others, to cover the time and resources required.

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FINANCIAL POLICY - We Want You To Be Informed!


FINANCIAL POLICY - We Want You To Be Informed!

Thank you for choosing our practice! We are committed to the success of your medical treatment and care. As part of this commitment, we provide several services as a courtesy to you, the patient, as outlined below:
If you have:You are responsible for:
As a courtesy to you, our staff will:
An HMO, POS, PPO, or other insurance with which we are contracted1) Obtaining a referral from your PCP (if applicable)
2) Payment of Co-pays & Deductibles at the time of service
File an insurance claim on your behalf
An HMO. POS, PPO or other insurance with which we are not contractedIf your insurance plan offers “out of network” benefits payment is REQUIRED at time of service based on your “out of network” benefits. Many insurance companies base their payment on “usual and customary” charges. The patient is responsible for ALL FEES above “usual and customary.” (UCR) If your insurance plan does not have “out of network” benefits, we will not file these claims. We will provide you the option to pay at the time of service with prompt pay discount.For POS and PPO, we will file an insurance claim on your behalf. HMO plans do not have out of network benefits and will not cover any charges. We will not file these claims. These patients will be provided the option to pay at the time of service with prompt pay discount.
Medicare without secondaryPayment of deductible and coinsurance at time of serviceFile an insurance claim on your behalf
Medicare, HMO, POS, PPO, and commercial ins. w/secondaryPayment of deductible and coinsurance at time of service if not covered by secondary insuranceFile an insurance claim on your behalf, as well as any claims to your secondary
Prompt Pay Patients

(Patients with no insurance, or those who choose NOT to file with insurance)
PAYMENT MUST BE MADE AT TIME OF SERVICE.

The discount DOES NOT apply if payment is not made IN FULL at time of service. Patient will be responsible for 100% of ALL charges incurred that day.
Providing a prompt pay discount for paying at time of service.

Patient or Provider WILL NOT file charges from that date of service with insurance of any sort.
Workers CompensationProvide us with the accident date, claim number, attending physician, employer, and adjuster information.File an insurance claim on your behalf
Accident Related (non Workers’ Compensation)Payment must be made in full at time of service or filed with your insurance plan (see above responsibilities), if a Lien is not on file. If the accident is related to an automobile accident, we will file with auto insurance. Auto insurance must be provided with claim number and med pay confirmed. If not on a Lien and not related to a work related injury or automobile accident, we will need written acknowledgement confirming this is not work or auto accident related and not being litigated.File an insurance claim on your behalf with required documentation (i.e. written acknowledgement confirming this is not work or auto accident relate and not being litigated.) If an auto accident, will file with auto insurance until Med Pay is exhausted. Once Med Pay has been exhausted, file insurance claim with health insurance including letter from auto insurance stating Med Pay is exhausted.
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BILLING PROCESS AND NOTICES


BILLING PROCESS AND NOTICES

We file insurance as a courtesy but this does not release the patient from financial obligation. We will attempt to verify benefits prior to your appointment to determine eligibility, deductibles, coinsurance, and obtain approval. THIS DOES NOT GUARANTEE REIMBURSEMENT. The patient remains fully responsible for the entire amount of the bill.

Charges not covered by insurance company, as well as applicable co-payments and deductibles, are patient’s responsibility. 

Patients are expected to pay for all estimated copay, deductible and co-insurance cost at time of service as required by insurance company. If for some unforeseen reason a patient cannot pay the co-payment, the patient will have the option to reschedule or agree to pay an additional $10.00 fee that will be added to the account for the collection cost of the co- payment, deductible and/or co-insurance after the date of service.

In order to help keep you informed, you will receive monthly statements or notices about your services with us as long as there is a balance on your account.

If we are filing insurance on your behalf, we will not send these statements to you until we have received payment or other information from your insurance. You may receive an EOB from your carrier, prior to our statements. You will continue to receive statements monthly, as long as there is a balance. After 90 days of statements, if you have not made payment arrangements, your account balance will be sent to CBA collection agency.

If you are scheduled for a procedure, PLEASE NOTE THE BILLING FOR THE PHYSICIAN AND FACILITY IS SEPARATE. The bill from the facility (surgery center or hospital) includes the costs of the procedure room, medical supplies, and medications. The physician bills separately for their services.

Patient signature below authorizes The Physicians Spine & Rehabilitation Specialists to release pertinent medical information to your insurance company when requested, or to facilitate payment of a claim.

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PRIVACY ACKNOWLEDGEMENT


PRIVACY ACKNOWLEDGEMENT

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AUTHORIZATION TO DISCLOSE / PROVIDE INFORMATION


AUTHORIZATION TO DISCLOSE / PROVIDE INFORMATION

My signature below indicates my authorization of any medical information including history, treatment, diagnosis, and prognosis to be released to:

The Physicians Spine & Rehabilitation Specialists

790 Church Street, Suite 550, Marietta, GA 30060 Phone: (770) 419-9902, Fax: (770) 419-7457

The Physicians Spine & Rehabilitation Specialists

5730 Glenridge Drive, Suite 100, Sandy Springs, GA 30328 Phone: (404) 816-3000, Fax: (678) 904-5797

The Physicians Spine & Rehabilitation Specialists

18 Riverbend Drive, Suite 100, Rome, GA 30161 Phone: (706) 314-1900, Fax: (706) 314-1901

The Physicians Spine & Rehabilitation Specialists

1060 Red Bud Road, Calhoun, GA 30701 Phone: (706) 314-1919, Fax: (706) 629-4904

The Physicians Spine & Rehabilitation Specialists

1035 Southcrest Drive, Stockbridge, GA 30281 Phone: (678) 275-2200, Fax: (678) 275-2201

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GENERAL CONSENT FOR CARE AND TREATMENT CONSENT


GENERAL CONSENT FOR CARE AND TREATMENT CONSENT

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

PATIENT RIGHTS & RESPONSIBILITIES

Patient Rights and Responsibilities are posted in the waiting room of the practice and are offered to patients.**Please note that this facility employs various types of licensed health care practitioners, including Medical Doctors (MD), Doctors of Osteopathic Medicine(DO), Registered Nurses (RN), Medical Assistants (MA), and Radiology Technicians (RT). As a patient, you have the right to inquire about a practitioner’s license.

My signature below confirms that I have read and understand my rights and responsibilities as a patient.

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By my signature, I acknowledge that I have read, understand, and agree to the policies and procedures of the Physicians Spine and Rehabilitation Specialists of Georgia, PC, as defined in the New Patient Packet that I received. I HEREBY CERTIFY that the information provided in these forms is complete, true and correct to the best of my knowledge.

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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