Date: ______ New Patient ( ) Returning Patient ( )

Date: ______New Patient o Returning Patient o

Patient Name: ______Patient Gender o Male o Female

Ethnicity: o Hispanic/Latino o Other Preferred Language: o English o Spanish o Other

Race: o American Indian or Alaska Native o Asian  Black or African American  Native Hawaiian or Other

Pacific Islander  White

Patient Address: ______

City: ______State: ______Zip: ______Email ______

Telephone: ______Work Phone: ______Cell Phone ______

Appointment Confirmation Preference: Phone  Email 

Patient Employer: ______

Occupation: ______

Social Security No.: ______Date of Birth: ______Age: ______

Spouse or Parent Name: ______

Referring Doctor Name: ______Telephone: ______

Primary Care Doctor: ______Telephone: ______

Social History:

Do you smoke:  Yes  No How much? Do you drink:  Yes  No How much per day?

Do you take illicit/street drugs:  Yes  No / Have you ever taken illicit/street drugs:  Yes  No

Are you pregnant:  Yes  No Delivery Date: How frequently do you exercise:

Previous Surgeries: Have you ever had an operation:  Yes  No

Type / Date / Location / Physician

Have you ever had problems with anesthesia:  Yes  No Explain: ______

PATIENT NAME: ______DATE OF BIRTH: ______

Present Injury Information : Height: ______Weight: ______

Body Part to be examined/complaint: ______

( ) Right ( ) Left ( ) Both Dominant hand:  Right  Left

Date of injury or first date of symptoms: ______

Is this injury result of:  Work Injury  Sports Injury  Auto Accident  Other

If work injury, please state in your own words what happened: ______

______

Have you had an MRI of this problem area  Yes  No If yes, at which facility? ______

For this current episode of care, please check if you have tried any of the following?

Over the counter/ At Home Physical Change in Injections

Anti-inflammatory meds Stretching Therapy Activity Level

If yes to any of the above, please describe______

Have you seen in the past or are you currently seeing a Pain Management provider?  Yes o No

If YES, please list the provider? ______

Are you current on your immunizations:  Yes  No Date of last tetanus: ______

Allergies to ANY Medicines:

ALLERGIES: ______

REACTION: ______

Review of Systems: (check for any symptoms you have experienced in the last 6 months)

Constitutional: ( ) Fevers ( ) Chills ( ) Weight loss

Eyes: ( ) Changes in vision ( ) Blurred vision ( ) Excessive tearing

Cardiovascular: ( ) Swelling of extremities ( ) Heart murmur ( ) Fainting

Respiratory: ( ) Shortness of breath ( ) Cough ( ) Wheezing

Gastrointestinal: ( ) Vomiting ( ) Constipation ( ) Diarrhea

Skin: ( ) Rash ( ) Itch ( ) Changes in mole or skin
Neurologic: ( ) Speech difficulties ( ) Seizure ( ) Numbness

Musculoskeletal: ( ) Limitation of motion ( ) Muscular weakness ( ) Joint Swelling

Hematologic: ( ) Easy Bruising ( ) Freebleeder ( ) NONE OF THE ABOVE

Other:

PATIENT NAME: ______DATE OF BIRTH: ______

Past Medical History

Are you currently having or have you ever had problems with your (check positive responses):

ENT: ( ) Hay fever/sinusitis ( ) Difficulty hearing ( ) Sleep Apnea

Pulmonary: ( ) Asthma ( ) COPD ( ) Emphysema

GI: ( ) GERD/gastritis/ulcer disease ( ) Constipation ( ) Diverticulosis

Cardiac: ( ) Hypertension ( ) Elevated cholesterol ( ) Heart disease ( ) Afib ( ) Valve problem

Urinary: ( ) Kidney Failure ( ) Enlarged prostate ( ) Bladder incontinence ( ) Kidney stones ( ) Multiple UTI

Endocrine: ( ) Diabetes ( ) Hypothyroid ( ) Metabolic Syndrome

Neurologic: ( ) Headache ( ) Seizures/Epilepsy ( ) Stroke ( ) Depression ( ) Balance problems

Infectious Disease: ( ) HIV/AIDS ( ) Hepatitis ( ) MRSA infection ( ) Cellulitis

Hematology: ( ) Anemia ( ) DVT ( ) Pulmonary embolus ( ) Leukemia ( ) Clotting Disorder

Cancer: Type: ______Body part: ______

Skin: ( ) Psoriasis ( ) Eczema ( )

Rheumatology: ( ) Rheumatoid arthritis ( ) Lupus ( ) Sjogren’s Disease

Phys. Review Date: / Initials: / Phys. Review Date: / Initials:
Comments: / Comments:
Phys. Review Date: / Initials: / Phys. Review Date: / Initials:
Comments: / Comments:

PATIENT NAME: ______DATE OF BIRTH: ______

Current Medication Information

Medications/Strength / Reason for Medicine / Dosage / Patient Initials / Physician Initials / Nurse
Initials

Are you allergic to any medications?

______

Have you been taking any over the counter medications? If so, which ones? ______

______

PREFERRED PHARMACY ______PHONE #:______

Patient Name: ______

Address: ______City______Zip______

PATIENT NAME: ______DATE OF BIRTH: ______

Athens Bone and Joint Prescription Policy

Medication Refill Policy:

1.  Refill requests may be made during regular office hours. Monday – Thursdays 8 am – 5 pm, Fridays 8 am – 4 pm. For refills that can be called in, please have your pharmacy fax a refill request to our office. Refill requests received after 3:00 pm will be filled the following business day. Please have refill requests faxed to 706-549-4795. Our office requires 48 hour notice for all narcotic/controlled prescription requests. All narcotic Schedule II prescriptions must be signed by a physician and picked up in the office during regular office hours.

2.  Refills will NOT be made after hours, on weekends or holidays. The on-call physician will not answer calls regarding medication refills.

3.  Patients are responsible for their controlled substance medication. You will need to be seen in our office every month for controlled medications as we do not handle long term pain management.

4.  Please remember to discuss any medication concerns and all refill requests you have with your physician at your regularly scheduled appointments. If you need refills and have an appointment, please request them at the time of your visit.

5.  If you have a formulary or a preferred medication, you MUST let our office know prior to the physician writing a prescription or calling in your medication. For example, if you want a brand name or need a less expensive medication, let our office know.

6.  Patients seeing a Pain Management provider will receive ONE PRESCRIPTION for controlled substances after surgery. After that, pain management responsibilities transition back to the Pain Management Specialist. It is your responsibility to keep your Pain Management provider abreast of your orthopedic treatment plan.

7.  If your account falls below good standing at any time, you will be required to schedule an appointment with a provider to receive prescriptions.

Narcotic and Controlled Substance Policy

It is extremely dangerous to receive prescriptions for narcotics and other controlled substances from several providers at the same time. Therefore, patients who do seek narcotic prescriptions through this office agree that, unless otherwise indicated by ABJ, we are to be the sole prescribing providers for this patient. Furthermore, patients desiring prescriptions for controlled substances from our office agree to grant us permission to contact pharmacies and other providers in order to ensure compliance with this policy. By signing this policy, the patient agrees to the following regulations in order to protect the patient and prescribing providers:

·  Patients in need of pain management will receive up to 90 days of narcotic medication following surgery or injury. After 90 days, patients needing longer term pain management will be referred to a Pain Management Specialist.

·  Random urine drug screens to track the usage of the controlled substance.(as required by Georgia Pain Rule 360-36-06)

·  Using only ONE pharmacy that is determined when signing this policy. Any change in pharmacies must be done in writing and before the refills are due.

·  Using only the prescribed dosage for the controlled substance. If pain is not controlled with current dosage, then the patient needs to contact the office to seek other alternatives. Patient is not advised to self-medicate.

·  Refills will only be given at the appropriate time; no early refills will be given regardless of the reason (i.e. stolen, lost, misplaced, using more than the prescribed dosage, etc.)

·  Patients are responsible for notifying our office when treated by an ER physician and given a controlled substance if also under treatment of care by an ABJ physician.

·  To not use any illegal controlled substances, including marijuana, cocaine, etc.

·  To not share, sell or trade medication with anyone.

·  To not attempt to obtain any controlled medicines, including opioid pain medicines, or controlled stimulants from any other doctor without disclosing to Athens Bone and Joint.

If we determine that any of the above policies have been violated, we will immediately cease all orders for any prescriptions and dismiss the patient from our office.

ACKNOWLEDGEMENT OF PRESCRIPTION POLICY

TODAY’S DATE: ______I have read and understand ABJ policies regarding prescriptions. I agree to the terms involved in the Prescription Policies and have received a copy of this policy. I understand that if any of the above policies are violated or I choose not to adhere to these policies I will be dismissed from this office and will not receive any refills from the providers. I also understand that I must choose a pharmacy at this time and will not switch the pharmacy unless I submit a written request.

Pharmacy: ______Location: ______

Patient/Patient representative’s signature ______ABJ employee: ______

PATIENT NAME: ______DATE OF BIRTH: ______

Payment Information

Guarantor information same as patient?  Yes  No

IF YOU CHECKED YES ABOVE, YOU CAN STOP HERE.

Guarantor Name: ______

Guarantor Gender:  Male Female

Guarantor Address: ______

Guarantor Telephone: ______Guarantor Work Telephone: ______

Guarantor Social Security No: ______Guarantor Date of Birth: ______

Guarantor Employer:

THIS PORTION IS ONLY REQUIRED IF YOU DO NOT HAVE YOUR INSURANCE CARD(S).

Primary Insurance Company: ______

Address: ______Phone Number: ______

Policy #:

Group #:

Group Name:

Secondary Insurance Company: ______

Address: ______Phone Number: ______

Policy #:

Group #:

Group Name:

If Student, Name of School: ______

PATIENT NAME: ______DATE OF BIRTH: ______

Patient Financial Policy

Thank you for choosing Athens Bone & Joint! We are committed to the success of your medical treatment and care. Please understand that a mutual financial understanding is part of our relationship.

We sincerely hope that by sharing our financial expectations we will strengthen the physician-patient relationship and keep the lines of communication open. This financial policy helps us provide quality care to our valued patients. If you have any questions or need clarification of any of the below policies, please feel free to contact our billing department at (706) 395-1673.

Payment is Due At the Time of Service

·  We accept cash, checks, debit, credit cards and Care Credit.

·  All co-payments, deductibles, co-insurance and fees for non-covered services are due at the time of service unless you have made payment arrangements in advance of your appointment.

·  Insurance required co-payments are due when you check in for your appointment. If you arrive without your co-payment, we may ask you to reschedule.

·  Patient-responsible balances are due when you check in for your appointment, unless prior arrangements have been made with the billing department.

·  In the event you need surgery we will provide you an estimate of your insurance required deductible and co-insurance amounts.

·  We request that at least 24 hour advance notice be given to the office if you will be unable to keep your scheduled appointment. This allows us to release your appointment time to another patient. We charge an administration fee of $50 for no-shows. Patients who repeatedly “no show” for appointments may be discharged from the practice.

Proof of Insurance

·  Please bring your insurance card(s) and a valid photo ID with you to each appointment.

·  It is your responsibility to notify the Practice of changes in your health insurance, address and phone number.

Self-Pay Accounts

·  We designate accounts, Self-Pay, under the following circumstances: (1) patient does not have health insurance coverage (2) patient is covered by an insurance plan that our providers do not participate in, (3) patient does not have a current, valid insurance card on file, or (4) patient does not have a valid insurance referral on file.

·  Self-Pay patients, please be prepared to pay a minimum of $425 on the date of service. There may additional fees for DME or other supplies or services. If you are unable to pay, please ask to speak to the billing department to make payment arrangements.

Divorce and Child Custody Cases

·  The parent or guardian who brings the child to the office for care is responsible for payment at the time of service no matter if the account is self-pay, participating insurance, or nonparticipating insurance. The Practice does not honor divorce specifics (e.g., percentage of financial responsibility).

·  If the child has coverage with a participating insurance plan and the proper insurance identification is present at the time of service, the Practice will bill that insurance company. Applicable co-payments, coinsurance and/or deductibles are due at the time of service, unless arrangements have been made with the office prior to arrival.

·  In cases of divorce, the individual who receives care is responsible for payment of co-payments, coinsurance, deductibles, and nonparticipating insurance balances at the time of service. We will not bill a divorced spouse for the patient’s services.

PATIENT NAME: ______DATE OF BIRTH: ______

Billing, Payments and Refunds

·  If we must send you a statement, the balance is due in full within 30 days of the statement date.

·  If you cannot pay the balance in full with 30 days, please contact our billing department to see if you qualify for special payment options.

·  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.

I have read, understand, and agree to the above Financial Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility.