230 North Hospital Drive, Suite #2

Russ Beecher, D.O.

230 North Hospital Drive, Suite #2

Price, UT 84501

(435) 613-PAIN (7246)

PATIENT REGISTRATION RECORD ______Patient Information

Last Name Middle First Name Account # (internal use)

Mailing Address (ex: P.O. Box) City State Zip

Home Phone Sex Birthdate Marital Status

Race Ethnicity Language How did you hear about us

Employer Position How Long Employed Work Phone

Primary Care Doctor Email Address Pharmacy

Responsible Party (If applicable and different from patient)

Last Name Middle First Name Account # (internal use)

Address City State Zip

Home Phone Sex Marital Status

Employer Position How Long Employed Work Phone

Primary Care Doctor E-mail Address

Emergency Contact

Name of Person or Nearest Relative Relationship

Address City State Zip Home Phone Work Phone

Insurance Co. Group # ID # Policy Holder Relationship to Insured Effective Date

Primary

Secondary

Other

The information provided is complete and accurate to the best of my knowledge.

Patient or Guarantor’s Signature Date Witness Initial

Payment Agreement & Payment Policy Acknowledgement

Welcome to our Practice. We appreciate your business and strove to maintain the highest quality of care possible while controlling health care costs. Please be aware of the following prior to your visit:

Release of Information Consent and Payment Terms

1. Your signature authorizes payment of medical benefits to go directly to Russ Beecher, DO. or its agents for any services furnished. Your signature requests that payment be made and authorizes release of any information necessary to process the claim. In case of a Medicare claim, the patient’s signature authorizes any entity to release to Medicare medical and non-medical information, including employment status, and whether the person has employer group health insurance, liability, no fault, workers compensation, or other insurance which is responsible to pay for the services for which the Medicare claim is made.

2. Your signature authorizes us to release medical information that may be necessary to request claim reimbursement from insurance companies or other payers to whom claims have been submitted and to release credit information to appropriate information gathering agencies.

3. The clinic cannot accept responsibility for collection of insurance, or other claims. The patient or guarantor is responsible for payment on the account in accordance with our policy. We anticipate payments on your account even though you may have an insurance claim pending per our contractual agreement with the plan.

4. In the event the account is sent to collection the patient or guarantor agrees to pay costs of collections, court cost and reasonable attorney’s fees. A collection cost of 21% to 50% of the original balance may be assessed to your account should the matter be referred to a collection agency.

5. In the event of suit the patient or guarantor agrees that Carbon County is the county of proper venue.

If you have no insurance

1. Actual charges cannot be determined until you see the provider, and your charges are added to your account by our data processing team. You will receive a 10% discount on your exam by paying in full on the date of the appointment. If you have a more extensive exam than normal care you will incur additional charges. These charges are also payable at the time of service. If you pay for your entire bill at the time services are rendered you are eligible for a 10% discount on the total charges. If you are interested in getting your discount, please discuss this with the receptionist.

2. Please be aware that it is impossible to estimate your charges prior to your exam. Therefore, it may become necessary to bill you for additional charges. If you receive a statement from us, payment is due 15 days from the date of your statement.

If you have insurance:

1. We will submit the charges to your insurance company(s) as a courtesy to you if:

a) You bring a current insurance card with you to each visit.

b) You pay any required co-payment at the time of service

2. Your insurance company may require a co-payment from you. Your contract requires this to be paid at the time of service. Your co- payment may not be your only liability. If your insurance carrier applies the billed charges to your deductible, denies the services, or considers the services non-covered, you may be responsible for payment of the service.

3. If your insurance plan requires a referral to authorize this visit, we require that you bring a written referral from your primary care physician or

verification that the referral has been called in to your insurance company. If you do not have the referral when you come, payment for the visit

becomes your responsibility until the referral is provided to our Physician.

4. Some insurance companies do not cover Routine Services (i.e. Routine Physical Exam). A normal Routine Exam may include Lab Tests and/or X- ray Tests in addition to the Exam and could result in a charge of more than $200.00. If your insurance does not cover Routine Services, please be

aware that you will be required to pay for any denied services.

5. It may become necessary to bill you for additional amounts due by you. If you receive a statement from us, payment is due 15 days from the date of your statement.

Medicaid Patients:

1. Medicaid does not cover Routine Procedures for patients older than 18 years of age. If you are over 18 years old and have a routine procedures

performed that are denied by Medicaid, you will be expected to pay for these services.

2. You are required to present your Medicaid Card at each visit. If you fail to show your card, and services are denied, you will be responsible for payment.

3. You will be held responsible for payment of any charges that are denied as “Not a Medicaid Benefit.”

Consent for Treatment: I hereby apply for and voluntarily consent to examination and treatment performed by the medical staff of Dr. Russ Beecher on the date noted below and all future visits.

MEDICARE LIFETIME AUTHORIZATION

I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical information about me release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that the payment of authorized benefits be made on my behalf; I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me.

I request the this authorization also apply to all other insurance

Signed: ______Date: ______

If signed by other than beneficiary, state the reason the patient was unable to sign.

Notice of Privacy Practices Acknowledgement

I acknowledge I have received a Notice of Privacy Practices stating how my personal health information may be used or disclosed by Dr. Russ Beecher.

I have read and understand all of the above information. I agree to pay for all charges incurred including any collection costs and reasonable attorney’s fees and other fees as described above.

Guarantor Signature: ______Date: ______

New Patient Form

Name______Date______

Date of Birth______Age______Referred by: ______

Reason for visit today______

What do you want to have happen as a result of this visit?

______

How and when did your problem begin?

______

Is today’s visit due to a job related injury? Yes/No If yes, please provide the following: Date of Injury:______

Workers Compensation company name:______

Case worker ______Contact number for case worker :______Case number______

Do you have pending litigation: Yes/No

Pain score today 0-10 (0=no pain 10=worst pain imaginable)? ______Average daily pain 0-10______

Please describe your symptoms: (Please circle all the apply) Sharp Burning Aching Stabbing Dull

Pins & Needles Throbbing Numbness Tingling Other ______

Previous Treatments? (Please circle all that apple to REASON for visit)

Tylenol Ibuprofen Naproxen Ice Heat Pain Medicine Muscle relaxants

Physical Therapy Chiropractic treatment Massage Yoga Surgery

Epidural injections or nerve blocks Other______

Previous Workup?

Xray CT MRI EMG Recent labs Other______

If yes, to any of the above workup; which facility was it done at?______

______

Name______Date______

Current Medications: (Please include all medications)

Medicine / Strength / Frequency / Last time taken
Date and time

Medical History: (Please circle all that apply) Diabetes Bleeding disorder Pacemaker

Sleep apnea Depression Anxiety Fibromyalgia Bipolar Disorder ADD/ADHD Rheumatoid arthritis

Others______

______

Any known drug allergies? Yes / No If yes, to what medication and what kind of a reaction did you have?______

______

WOMEN: Last menstrual cycle?______

Surgical History: Hospitalizations:

Date Mo/Year / Surgery / Date Mo/Year / Reason

Name______Date______

Family History: (Please mark all that apply)

Diabetes High Blood Pressure Heart disease Osteoporosis Other

Mother
Father
Brother #1
Brother #2
Brother #3
Sister #1
Sister #2
Sister #3
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Adopted

Social History: Single Married Divorced Widowed

Number of children: Son(s)?______Daughter(s)?______

Tobacco Use: Non user

Current Tobacco user: Chewing Tobacco Cigarette

How soon after you wake up do you use tobacco? ______How many times daily do you use tobacco?______

Are you interested in quitting? Yes / No

Former User: When did you quit?______

Alcohol Use: Non User

Current User: 1 monthly or less 2-4 times a month 2-3 times a week 4 or more a week

Type(s)?______How many drinks per sitting?______

Former User: How long has it been since your last drink? ______

Illegal drugs? Yes / No If yes, what and how long has it been?______

Previous personal or family history of sexual, emotional, physical or substance abuse? Yes / No

If yes, please explain______

Name______Date______

Please mark on the diagram where you have your symptoms

Have you recently experienced any of the following? (Please circle all that apply)

Gen: Chills Fever Unexpected weight loss/gain more than 10 lbs. Night sweats

Eyes: Blurry Vision Dryness

ENT: Dry Mouth Hearing Loss Throat Soreness

Resp: Cough Pain with breathing Shortness of breath

CV: Chest pain Heart beat irregular

GI: Constipation Diarrhea Nausea/vomiting Stool Incontinence

GU: Incontinence Kidney problems Painful urination

MSK: Arthritis Joint Pain Muscle ache

Skin: Lesion(s) Rash Skin changes

Neuro: Headache Numbness/Tingling Sleeping difficulties

Psych: Anxiety /worry Depression Mood swings

Endo: Fatigue Thyroid problems

Heme: Anemia Bruising easily Slow to heal

Allergic/Immunologic: Frequent infections Seasonal allergies

SOAPP® Version 1.0

Name: ______Date: ______

The following are some questions given to all patients at the Pain Management Center who are on or being considered for opioids for their pain. Please answer each question as honestly as possible. This information is for our records and will remain confidential. Your answers alone will not determine your treatment. Thank you.

Please answer the questions below using the following scale:

0 = Never, 1 = Seldom, 2 = Sometimes, 3 = Often, 4 = Very Often

1. How often do you feel that your pain is “out of control”? 0 1 2 3 4

2. How often do you have mood swings? 0 1 2 3 4

3. How often do you do things that you later regret? 0 1 2 3 4

4. How often has your family been supportive and encouraging? 0 1 2 3 4

5. How often have others told you that you have a bad temper? 0 1 2 3 4

6. Compared with other people, how often have you been in a car accident? 0 1 2 3 4

7. How often do you smoke a cigarette within an hour after you wake up? 0 1 2 3 4

8. How often have you felt a need for higher doses of medication to treat your pain? 0 1 2 3 4

9. How often do you take more medication than you are supposed to? 0 1 2 3 4

10. How often have any of your family members, including parents

and grandparents, had a problem with alcohol or drugs? 0 1 2 3 4

©2008 Inflexxion, Inc. Permission granted solely for use in published format by individual practitioners in clinical practice. No other uses or alterations are authorized or permitted by copyright holder. Permissions questions: . The SOAPP® was developed with a grant from the National Institutes of Health and an educational grant from Endo Pharmaceuticals.

0 = Never, 1 = Seldom, 2 = Sometimes, 3 = Often, 4 = Very Often

11. How often have any of your close friends had a problem with alcohol or drugs? 0 1 2 3 4

12. How often have others suggested that you have a drug or alcohol problem? 0 1 2 3 4

13. How often have you attended an AA or NA meeting? 0 1 2 3 4

14. How often have you had a problem getting along with the doctors who

prescribed your medicines? 0 1 2 3 4

15. How often have you taken medication other than the way that it was prescribed? 0 1 2 3 4

16. How often have you been seen by a psychiatrist or a mental health counselor? 0 1 2 3 4

17. How often have you been treated for an alcohol or drug problem? 0 1 2 3 4

18. How often have your medications been lost or stolen? 0 1 2 3 4

19. How often have others expressed concern over your use of medication? 0 1 2 3 4

20. How often have you felt a craving for medication? 0 1 2 3 4

21. How often has more than one doctor prescribed pain medication for you 0 1 2 3 4

at the same time?

22. How often have you been asked to give a urine screen for substance abuse? 0 1 2 3 4

23. How often have you used illegal drugs (for example, marijuana, cocaine, etc.)

in the past five years? 0 1 2 3 4

24. How often, in your lifetime, have you had legal problems or been arrested? 0 1 2 3 4

Please include any additional information you wish about the above answers. Thank you.