General Surgery Clinic

1430 College Drive, Suite B

Mt. Carmel, IL 62863

Phone: 618-263-6190 Fax: 618-262-7351

Date:

Dear ,

We look forward to seeing you on .

In an effort to expedite your time and ours, we pre-register our patients prior to their visit. Please complete the forms that are included with this letter. You may mail them, fax them or bring them in to our office but we need them back at least two (2) days prior to your appointment. Incomplete papers or papers not returned prior to appointment may require that we reschedule your appointment.

Please note that directions to our office are on the back of this letter.

At the time of each of your appointments, please come prepared with the following items; your insurance card, a photo ID and a list of your current medications including the name, strength, and directions for taking them. This is required at each visit.

If you cannot keep your appointment, please call us one business day ahead so that another patient can be scheduled. If you have any questions or need assistance please call our office at 618-263-6190. Our fax number is 618-262-7351.

Respectfully,

WGH General Surgeons Office

General Surgery Clinic

1430 College Drive, Suite B

Mt. Carmel, IL 62863

Phone: 618-263-6190 Fax: 618-262-7351

If you are coming from Rt. 1, North: Turn right on 13th street. Go two blocks to college drive. Turn right on college drive. Continue on college drive. We are located in the curved front brick building that also has Dr. L.P. Jennings’ office. There is a brick marquee in front of the office that lists Dr. Jennings and Dr. Oppeltz name.

If you are coming from Rt. 1, South: Turn left on market street. Continue until Market Street becomes college drive. Continue on college drive. We are located in the curved front brick building that also houses Dr. L.P. Jennings’ office. There is a brick marquee in front of the office that lists Dr. Jennings and Dr. Oppeltz name.

If you are coming from Indiana HWY 64: IN-64 becomes IL- 15/South walnut street. Turn right on 3rd street to Market Street. Turn left on Market Street. Continue until Market Street becomes college drive. Continue to college drive. We are located in the curved front brick building that also houses Dr. L.P. Jennings’ office. There is a brick marquee in front of the office that lists Dr. Jennings and Dr. Oppeltz name.

If you are coming from Rt. 15 South: Turn left at market street. Continue on until Market Street becomes college drive. Continue on college drive. We are located in the curved front brick building that also houses Dr. L.P. Jennings’ office. There is a brick marquee in front of the office that lists Dr. Jennings and Dr. Oppeltz name.

WabashGeneralHospital

General Surgery Department

Notice to the Public: Provider-Based Status

Thank you for choosing Wabash General Hospital General Surgery for your surgical needs. You are visiting a facility that functions as an outpatient department of WabashGeneralHospital. This posting is intended to inform patients about our provider-based billing practices and how it affects you as a patient.

What does “provider-based” or “hospital outpatient” billing mean?

“Provider-based” or “hospital outpatient” billing refers to the billing process used for services provided in a hospital outpatient facility. This is where the physician/provider is employed by the hospital and the hospital owns the space and provides support staff for the physician/provider. It breaks out the charges for each office visit or service, with part of the total for the mainpersonyou see (your provider), and the rest for theplace (building, support staff, equipment and other overhead).

How does this affect my billing?

Patients may receive a charge from the hospitaland the physician/provider in a hospital outpatient setting. If a patient has insurance, each patient’s insurance plan is unique to that patient and contracted provider. Some insurance companies may cover both hospital charges and doctor charges and some may not.

How does this affect a patient who has Medicare or Medicaid?

In a hospital based clinic, Medicare and Medicaid patients may receive two separate bills for services provided in the office- one from the provider and one from the hospital. Depending on the clinical service being provided, additional out ofpocket expenses for Medicare and Medicaid patients may be incurred in the “Provider-Based” facility.

What if a Medicare or Medicaid patient has secondary insurance coverage?

Co-insurance and deductibles may be covered by a secondary insurance policy. Check with your benefits or insurance company for details related to your secondary coverage. For instance, you may ask whether the secondary insurance company covers facility charges or provider-based billing. If it does, ask what percentage of the charge is covered. Verify what your hospital outpatient insurance benefits are, as they typically are applied toward your deductible and coinsurance.

Medical Records
Medical Records for patients treated in either the outpatient clinics or the hospital should be available for review at the different sites of care.

Which WGH locations/departments are “provider-based”?

WGH Orthopaedic & Sports Medicine Department (Mount Carmel Location)

WGH General Surgery Department

WGH Oncology Department

WGH Primary Care

In Summary: Receiving care at WabashGeneralHospital’s “Provider-Based” locations may result in a facility charge as well as a professional or physician charge for outpatient services and/or procedures. These charges will be reflected on the patient statement you receive for services provided. Your insurance plan will determine the impact this has on your out-of-pocket expenses. Wabash General Hospital is not unique in billing this method.

Patients are advised to review their insurance benefits or contact their insurance provider to determine what their policy will cover and identify any out-of-pocket expenses. For more information please contact our business office at (618) 262-8621.

General Surgery Clinic

1430 College Drive, Suite B

Mt. Carmel, IL 62863

New Patient Information

Full Name -

Date of Birth - Age -Gender -

Marital Status -Race -

SSN - What Pharmacy do you use: ______

Phone Number -

Email Address -

Address/City/State -

Employer/Address -

Emergency Contact Name/Number -

Emergency Contact Relationship/Date of Birth -

Referring Physician -

Primary Physician -

Insurance Information

Primary Insurance -

Primary Holder Name/DOB/SSN -

Policy #/ Group # -

Secondary Insurance -

Secondary Holder Name/DOB/SSN -

Policy #/ Group # -

I hereby authorize the release of any medical information necessary for the processing of insurance. I hereby assign all medical and or surgical benefits to include major medical benefits to which I am entitled to WGH photocopy is considered valid. I certify the above information is correct to the best of my knowledge. I also understand that I am financially responsible for all charges.

Signature: Date:

General Surgery Clinic

1430 College Drive, Suite B

Mt. Carmel, IL 62863

Guarantor- only complete if you are under 18 or have a POA (person responsible for bill)

Guarantor Name-

Date of Birth- Age-Gender-

Relationship to Patient- SSN-

Phone Number- Work Number-

Home Address/City/State/Zip-

Employer/Employer Address-

Signature: Date:

General Surgery Clinic

1430 College Drive, Suite B

Mt. Carmel, IL 62863

Privacy Questionnaire and Policy Disclosure Statement

Please note: If this section is not completed, we are unable to discuss these issues or release information to anybody other than you (and those entities allowed by law).

List the family member(s) or other person(s) that we may inform of your medical condition, treatments, appointments, and account information.

Name/Relationship: ______Phone Number:______

Please print the address of where you would like correspondence from our office to be sent if other than your home address.

Can confidential messages be left on your home telephone answering machines? Yes/No

I am aware that medical records for patients treated in either the outpatient clinic or the hospital will be available for review at the different sites of care. These sites of care include WGH Primary Care, WGH Orthopaedic Department, WGH General Surgery Department and WGH Oncology Department.______(patient/guardians initials).

I ______(the patient/ patient’s legal representative) hereby grant permission to Richard F. Oppeltz, M.D. to perform such examinations and medical and therapeutic procedures professionally deemed necessary or advisable for the patient’s diagnosis and treatment.

I verify that I have been offered and/or received a copy of Wabash General Surgeon’s Notice of Privacy Practices (NPP) in regards to the HIPAA Privacy Act.

Patient Name Printed: ______Date: ______

Patient Signature: ______

General Surgery Clinic

1430 College Drive, Suite B

Mt. Carmel, IL 62863

Financial Agreement and Authorization for Treatment

I understand that I am seeking treatment from Wabash General Hospital’s Provider-Based Clinic. I am aware that there may be separate charges for the hospital and physician. Depending on the services provided, additional out-of-pocket expenses may be incurred. Patients are advised to review their insurance benefits or contact their insurance provider to determine what their policy will cover.

Wabash General Hospital General Surgery Clinic will complete forms at the patient’s request. A $15 fee will be charged for each set of forms, payment is due prior to completion.

Patient Name Printed:Date:

Patient Signature:

General Surgery Clinic

1430 College Drive, Suite B

Mt. Carmel, IL 62863

Please complete the following questionnaire. Leave blank any parts you are unsure of, or do not wish to answer. Your answers will help with providing your care. We will review this form with you during your examination. All information will be kept confidential.

Patient Name:

What is the reason for your visit today?

History of your current problem (when it started, your symptoms and treatment if any):

Caffeine Use: What Kind: How Much:

Tobacco Use: Yes / No Current Former

Type: Smoking: How Often:Packs per Day:

Snuff (between lower lip and gum):How Often:Cans per Day:

Chew (between cheek and gum):How Often:Cans per Day:

Quit Date:

Alcohol Use: Yes/No Current Former

How Often: How Much:

Illicit Drug Use: Yes/ No Current Former

How Often: How Much:

Have you had any recent falls in the last 12 months: Yes / No

If yes, any injury from the fall: ______

Dominant Hand: Left/ Right

General Surgery Clinic

1430 College Drive, Suite B

Mt. Carmel, IL 62863

Your medical history: Please check all previous illness or conditions below.

__ Chronic Obstructive Pulmonary Disease__ Hypothyroidism (Underactive Thyroid)

__ Asthma__ Liver Disease

__ Hypertension (High Blood Pressure)__ Hyperparathyroidism

__ Coronary Artery Disease__ History of Hepatitis

__ Myocardial Infarction (Heart Attack) __ History of Stroke

__ Congestive Heart Failure__ Epilepsy (Seizures)

__ Hyperlipidemia (High cholesterol)__ Chronic Renal Failure

__ Diabetes__ Obesity

__ Hyperthyroidism (Overactive Thyroid) ______Height ______Weight

Do you have a history of prior cancers?

Any other problems not listed?

Do you take any blood thinning medication? If so, please list which one and why: ______

______

Blood Transfusion: Yes / No If Yes: When ______

Surgical History:

Type: Approximate Date:

Have you ever had a colonoscopy? If so, when? ______

Have you ever been hospitalized? Yes / No Hospital: ______

Please tell us the reason why and when?

General Surgery Clinic

1430 College Drive, Suite B

Mt. Carmel, IL 62863

Current Medications (include hormones, over the counter drugs, vitamins, and herbs):

Name of Medicine:Dosage:How often:Tablet/Capsule:Reason for taking:

Are you allergic to anything? __ Yes __ No

List all ALLERGIES to anything and describe your reaction.

Allergies:Reaction:

Food:

Drug:

Latex:

General Surgery Clinic

1430 College Drive, Suite B

Mt. Carmel, IL 62863

Review of Systems: Please check all of the following problems you are having now.

GeneralMusculoskeletalGastrointestinal

__ Chills__ Back Pain__ Abdominal Pain

__ Fever__ Bone Pain__ Black Stools

__ Decreased Appetite__ Joint Pain__ Blood in stool

__Night Sweats__ Joint Stiffness__ Difficulty Swallowing

__ Weakness/ Fatigue__ Muscle Pain__Constipation

__ Heartburn__ Trauma/Injury (______)__ Diarrhea

__ Weight Gain__ Heartburn

__Weight Loss__ Nausea

__ Painful Swallowing

EndocrineHem/Lymph__ Vomiting

__Cold Intolerance__ Anemia

__Heat Intolerance__ Easy Bruise/ Bleed

__Diabetes__ Lymphedema (Swelling)Neurological

__Polydipsia (Excessive thirst)__ Swollen Glands__Confusion

__ Hot Flashes__ Dizziness

__Fainting

Eyes Head/Ears/Nose/Throat__Headache

__ Blurred Vision__Hearing Changes__Lightheadedness

__Double Vision__ Hearing Loss__Memory Changes

__Vision Changes__Hoarseness__Numbness: (______)

__Yellow Eyes__Nose Bleeds__Seizures

__Runny Nose__ Focal Weakness

Genitourinary__ Sore Mouth

__ Blood in Urine__ Throat PainPsychiatric

__ Burning Urination__ Depression

__Difficulty Controlling UrineRespiratory__Hallucinations

__Frequency__Cough__ Anxiety

__Sexual Dysfunction__Coughing Blood__Substance Abuse

__Urgency__Shortness of Breath__Suicidal Thoughts

__Vaginal Bleeding__ Sputum Production

__Vaginal Problems__WheezingSkin

__Bruises

BreastCardiovascular__Bumps

__ Breast Pain__Chest Pain__ Changes in Moles

__Breast Mass__ Palpitations__Itching

__Nipple Discharge__Leg swelling__Rash

__Skin Changes__ Paroxysmal Nocturnal Dyspnea__Skin Changes

(Shortness of Breath & coughing

At night)

__ Orthopnea

__ Shortness of breath laying down

flat

General Surgery Clinic

1430 College Drive, Suite B

Mt. Carmel, IL 62863

Family Medical History:

AgeDiseasesIf Deceased, Cause of Death

Father

Mother

Sisters

Brothers

Others

Check if your blood relatives had any of the following:

Relationship to you: Paternal (Fathers Side)

Maternal (Mothers Side) Alive/Deceased

Arthritis

Asthma

CancerType:

Chemical Dependency

Colon Polyps

Diabetes

Heart Disease

High Blood Pressure

Kidney Disease

Stroke

Tuberculosis

Other (specify)______