Name: (Last) ______________________(First)_______________________(Middle)_____________(Nickname)__________________

Date of Birth: _______/________/________ Age: _______ Sex: M F Marital Status: S M D W Phone (______) _________-_____________ Cell(______)_________-_____________ SSN:__________/__________/__________

Address: ___________________________________________City:____________________ST:_____________Zip:_______________

Email Address: _______________________________________________________________________________________________

Employer: ______________________________________________________________ Phone (______)_________-_____________

School if Student: ____________________________________________________________________ Full time Part time

Primary Care Physician: ________________________________________________________________________________________

Referred by: _________________________________________________________________________________________________ Physician Hospital Family/Friend Advertisement Coach Other

IN CASE OF EMERGENCY, I GIVE PERMISSION TO NOTIFY:

Name: ___________________________________________________________ Home (______)_________-_____________

Relationship______________________________________________________ Cell (______)_________-_____________

HEALTH INSURANCE INFORMATION: Please give information about the holder of insurance

Primary: Secondary: Insurance Company: ____________________________________ Insurance: Company___________________________________

Insured Name: ________________________________________ Insured Name: _______________________________________

Relationship to patient: _________________________________ Relationship to patient________________________________

SSN: __________________________ DOB: _________________ SSN: ________________________ DOB: __________________

Policy or ID number: ___________________________________ Policy or ID number: _________________________________

Group number: _______________________________________ Group number: ______________________________________

Employer: ____________________________________________ Employer: ___________________________________________

If patient is a minor please give parental or guardianship information Parent or Guardian____________________________________________________________________________________________

Relationship___________________________________________SSN:__________________________ DOB:____________________

What pharmacy do you use?_____________________________ ____________________________________ _______ (Initial) I agree that may request and use my prescription medication history from other healthcare providers, third-party pharmacy benefit payors, or Health Information Exchanges for treatment purposes.

The CMS Meaningful Use initiative requires we ask certain demographic information questions (below). ____Do Not Wish to Answer the Following Questions:

Language Choice __________________________ Race: White Black Asian Native American Hispanic Native Hawaiian Unknown Ethnicity: Hispanic Non-Hispanic Unknown

DATE: __________________________________

Patient name__________________________________________________________ DOB ______________________

What are we seeing you for today? Head Neck Shoulder Elbow Wrist Hand Finger Back Hip Knee Ankle Foot ToesRibs Face Abdomen Breast Other_____________________ Right Left Both

Were you injured? � YES � NO If Yes, HOW? ______________________________________________________

_______________________________________________________________________________________________

Date your symptoms began? __________________________

Is This A Work-Related Accident? � YES � NO If Yes, list Employer and/or Adjuster’s name and phone:

_________________________________________________________________________________________

Is This An Auto-Related Accident? � YES � NO

Are you represented by an attorney? � YES � NO If Yes, list attorney’s name and phone: _________________________________________________________

CURRENT MEDICATIONS AND ALLERGIES: (use back of form if needed)

_____________________________________________mg__________________ How often? ______________________

_____________________________________________mg__________________ How often? ______________________

_____________________________________________mg__________________ How often? ______________________

_____________________________________________mg__________________ How often? ______________________

Allergies to Drugs:_______________________________________________________ No Known Drug Allergies

Allergies to: Latex Adhesive Tape Iodine Other _____________________________________________

Are you Pregnant? Yes No

If Yes, list responsible party and insurance

company, adjustor’s name, claim number

and phone. If unknown, write ‘Unknown’:

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

If Yes, please indicate how your account will be billed:

MVA (Self-Pay) Health Ins.

NOTE: Be advised all MVA(Self-Pay) accounts require payment for initial evaluations and payment for further treatment is expected at date of service; any surgery deposits will be due prior to scheduling.

Patient name__________________________________________________________ DOB ______________________

Please list how you would like to be contacted, for appointment reminders:

Text Message Voicemail at (______) ______ - __________ This is my: Cell Phone Home PhoneWork Phone

Please indicate which phone number we may leave a voicemail with clinical information:

(______) ______ - __________ This is my: Cell Phone Home Phone Work Phone

Who may we talk to on your behalf?

_______ (Initial) I permit to discuss health information in person or by phone with the following family members or friends. Release of information under this document is limited to verbal discussion with my Health Care Provider. This document does not permit release of any written health information to the individuals named below.

NAME PHONE NUMBER RELATIONSHIP

______________________________________________ _____________________________ _______________________

______________________________________________ _____________________________ _______________________

I attest that the information stated on this document is true and correct to the best of my knowledge, and agree to contact and inform of any changes to the information stated herein.

X________________________________________________________________________________________________ Signature of patient, parent or legal guardian/ relationship is required

Patient Intake

[THIS SECTION IS FOR STAFF USE]

Patient name__________________________________________________________ DOB ______________________

Patient Intake for:

Head Neck Shoulder Elbow Wrist Hand Finger Back Hip Knee Ankle Foot ToesRibs Face Abdomen Breast Other_____________________ Right Left BothWork – RelatedMotor Vehicle – Related

Date of Injury: ___________________________________________

PATIENTS: PLEASE COMPLETE THE ALL THE QUESTIONS BELOW THIS LINE:

Are you in Pain Management? Yes No If Yes, Dr. ___________________________________________________ Do you have a Cardiologist? Yes No If Yes, Dr. ___________________________Phone______________________ Last Influenza Vaccination (date): ______________ Last Pneumonia Vaccination (date): _______________

REGARDING CURRENT INJURY: Were you treated at a hospital or by another physician? � YES � NO If YES, by Whom and When? _____________________________________________________ Have you had X-ray MRI CT Scan Ultrasound Other(________________________________________)? If Yes, list Where and When: _________________________________________________________________ Have you had surgery before for this? � YES � NO If Yes, list Date and Type: ____________________________________________________________________ Who performed the surgery? _________________________________________________________________

MEDICAL HISTORY: (Check all that apply) Osteoarthritis Osteomyelitis Hepatitis Blood Clots Heart AttackHeart Failure High Blood Pressure Depression Heart Murmur StrokeRheumatic Fever Chest Pain/Angina Asthma Emphysema DiabetesCOPD Recurrent Bronchitis Anemia Sickle Cell HIVAIDS Rheumatoid Arthritis Fractures Paralysis Head injuryCancer of

the________________Tuberculosis (Circle one:

Currently Active TB or Inactive TB)Pacemaker Other

__________________

SOCIAL HISTORY: Have you ever been addicted or dependent on drugs or pain medicine? Yes NoSmoke: Every Day Some Days Never Smoker Former Smoker Quit in ________Drink: Yes No If YES: beer, alcoholic drinks, wine (Circle one) How much per month?_____________

SURGICAL HISTORY: Date: __________________________________________________________________________________________________ __________________________________________________________________________________________________

Patient name__________________________________________________________ DOB ______________________

FAMILY HISTORY: (List relatives with conditions) Medical Condition Relative (mother, brother…) Medical Condition Relative (mother, brother…)

Bleeding Tendency DiabetesBlood Clot Heart AttackCancer Heart diseaseHigh Blood Pressure OsteoarthritisRheumatoid arthritis StrokeTuberculosis Depression

CURRENT REVIEW OF SYSTEMS:(Check all that apply) Fever Rapid weight loss or gain JaundiceSwollen ankles Night sweats PalpitationsChest pain/angina Numbness or tingling Weakness of arm or legTaking blood thinners Excessive bleeding Shortness of breathHearing loss Vision changes RashActive infection of _________________ Other____________________________ Other____________________________

I attest that the information stated on this document is true and correct to the best of my knowledge, and agree to contact and inform of any changes to the information stated herein.

X________________________________________________________________________________________________ Signature of patient, parent or legal guardian/ relationship is required

ASSIGNMENT OF BENEFITS – FINANCIAL AGREEMENT I hereby give authorization for payment of insurance benefits to be made directly to OrthoLinks Orthopedics, for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collection, and reasonable attorney’s fees. Refunds will be issued upon request.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If item 9 of the HCFA-1500 claim form is complete, my signature authorizes releasing of the information to the insurer of the agency shown.

In Medicare assigned cases, the physician/supplier agrees to accept the charge determination of the Medicare carrier as the full charge and the patient is responsible only for the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier.

I hereby authorize this healthcare provider to release all necessary information to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.

Signature of Patient or Legal Representative: ___________________________________________________

HIPAA Compliance

As mandated by the Federal Government and Office of Civil Rights, OrthoLinks Orthopedics is required to follow the HIPAA Compliance Act to ensure patient confidentiality. I understand that as part of my healthcare, OrthoLinks Orthopedics , maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care treatment.

I understand that this information serves as a 1) basis for planning my care and treatment; 2) means of communication amount the many healthcare professionals who contribute to my care; 3) source of information for applying my diagnosis and surgical information to my bill; 4) means by which a third-party can verify that services billed were actually provided; 5) a tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals.

I understand that I have the right: 1) to object to the use of my health information for directory purposes: 2) to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operation – and that the organization is not required to agree to the restrictions requested: 3) to revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

Comments and Restrictions: ______________________________________________________________________

If you are 18 and your Parent is responsible for payment, you must sign this release.

I authorize release of billing / medical information to: Parent Spouse Guardian Other

Name of authorized person(s) _____________________________________________________________________

Detailed message regarding test results can be left on my answering machine: Yes No

_______________________________ _________________________ Signature of Patient or Legal Representative Date

PERMISSION FOR TREATMENT

I, the undersigned, hereby voluntarily consent to medical care/diagnostic treatment and or minor surgical treatment by Orthopedics deemed advisable and necessary in the diagnosis and treatment of my condition. I am aware that the

practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as result of treatment or examination in the office. I authorize the release of any of my past/current medical records that are needed for my treatment from any prior healthcare providers.

AUTHORIZATION AND ASSIGNMENT

I request that the payment of Authorized Medicare/Insurance Benefits be made either to me or on my behalf for any services furnished by Orthopedics, I authorize any holder of medical information about me to release to CMS/Insurance carriers and it’s agents any information needed to determine these benefits or benefits related to services. I hereby authorize Orthopedics to furnish information to CMS/Insurance carriers concerning my medical condition, illness and treatment to determine the benefits for related services. I hereby authorize (assign) my insurance carrier(s)/CMS to make payment directly to Orthopedics for medical/diagnostic/surgical benefits payable by me. I understand and agree (regardless of my insurance status), that I am ultimately responsible for the balance of any professional services rendered. I understand that I am responsible for any charges incurred if my account is sent to a collection agency and for any returned checks. I understand that CMS and /or other insurance carriers do not cover all office services/procedures. I agree to take full responsibility for any unpaid balances and that such payment will be made to the best of my knowledge. I will also notify you of any changes in my status or changes in the above information.

I certify that I have read and understand all above information. I am authorizing treatment and authorizing my insurance to be billed for that treatment. I also certify that the information I have given here is true and correct to the best of my knowledge. I will notify you of any changes in my status or changes in the above information.

Signature:______________________________________________ Date:_ ___________________

Patient Name (Print):________________________________________ SS#:_____________________

Witness:_______________________________________ Relationship:_________________________

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Patient's Name: ________________________________________DOB:_____/_____/________

I authorize release of my health information records to OrthoLinks Orthopedics to enable a comprehensive review of my medical care. I authorize the following physician offices, clinics, hospitals, other health care providers, pharmacies and legal offices to provide copies of my health information to: OrthoLinks ORTHOPEDICS 4450 E Fletcher Ave Suite C Tampa, FL 33613

OFFICE: 813-336-5237 FAX: 813-336-2112 (List of all facilities, clinics, and offices from which information will be requested)

PHYSICIAN OFFICES (please list all physicians you have seen in the past two years) Physician's Name Address Phone Number

1.

2.

3.

4.

PHARMACY (please provide an updated list of all pharmacies that you have used in the past two years) Pharmacy Name Address Phone Number

1.

2.

3.

4.

HOSPITAL AND OTHER FACILITIES (for surgeries/procedures, MRI/CT SCANS and any LAB and X-RAY reports) Facility Name Address Phone Number

1.

2.

3.

4.

Restrictions: __________ There are NO restrictions on the information that can be released. __________ The following information CAN NOT be released: _____________________________________________________________________________________________

DURATION: This authorization shall be effective immediately. I understand this authorization to release medical records will become invalid when I am no longer a patient of OrthoLinks Orthopedics. I understand I have the right to revoke this authorization, at any time by sending written notification to the Privacy/Compliance Officer at the above listed address.

_________________________________________________________________________________ Signature of patient or personal representative Date (PLEASE PRINT) Name of patient or personal representative: __________________________________________________________ (PLEASE PRINT) If personal representative, describe authority: __________________________________________________________

registration 912014Intake Form912014OrthoLinks NP PaperWork.pdf32320099.pdf

Name Last: First: Middle: Nickname: Date of Birth: undefined: undefined_2: Age: Sex: Phone: Cell: undefined_6: SSN: undefined_7: undefined_8: Address: City: ST: Zip: Email Address: Phone_2: undefined_9: undefined_10: School if Student: Full time: Part time: Primary Care Physician: Referred by: Physician: Hospital: FamilyFriend: Advertisement: Coach: Other: Name: Home: undefined_11: undefined_12: Relationship: undefined_13: undefined_14: undefined_15: Insurance Company: Insurance Company_2: Insured Name: Insured Name_2: Relationship to patient: Relationship to patient_2: SSN_2: DOB: SSN_3: DOB_2: Policy or ID number: Policy or ID number_2: Group number: Group number_2: Employer_2: Employer_3: Parent or Guardian: Relationship_2: SSN_4: DOB_3: What pharmacy do you use: Location: Initial I agree that SOS may request and use my prescription medication history from other healthcare: Do Not Wish to Answer the Following Questions: Language Choice: White: Black: Asian: Native American: Hispanic: Native Hawaiian: Unknown: Hispanic_2: NonHispanic: Unknown_2: Patient name: DOB_4: Head: Neck: Shoulder: Elbow: Wrist: Hand: Finger: Back: Hip: Knee: Ankle: Foot: Toes: undefined_16: Ribs: Face: Abdomen: Breast: Right: Left: Both: If Yes HOW: Were you injured YES: Date your symptoms began: Is This A WorkRelated Accident: MVA SelfPay: Health Ins: and phone If unknown write Unknown 1: and phone If unknown write Unknown 2: and phone If unknown write Unknown 3: and phone If unknown write Unknown 4: and phone If unknown write Unknown 5: If Yes list attorneys name and phone: CURRENT MEDICATIONS AND ALLERGIES use back of form if needed 1: CURRENT MEDICATIONS AND ALLERGIES use back of form if needed 2: CURRENT MEDICATIONS AND ALLERGIES use back of form if needed 3: CURRENT MEDICATIONS AND ALLERGIES use back of form if needed 4: mg: How often: mg_2: How often_2: mg_3: How often_3: mg_4: How often_4: Allergies to Drugs: No Known Drug Allergies: Latex: Adhesive Tape: Iodine: undefined_17: Are you Pregnant: Patient name_2: DOB_5: Please list how you would like to be contacted for appointment reminders: undefined_18: undefined_19: Text Message: Voicemail at: Cell Phone: Home Phone: Work Phone: Please indicate which phone number we may leave a voicemail with clinical information: undefined_20: undefined_21: Cell Phone_2: Home Phone_2: Work Phone_2: Who may we talk to on your behalf: NAME 1: NAME 2: PHONE NUMBER 1: PHONE NUMBER 2: RELATIONSHIP 1: RELATIONSHIP 2: contact and inform SOS of any changes to the information stated herein: Patient name_3: DOB_6: Head_2: Neck_2: Shoulder_2: Elbow_2: Wrist_2: Hand_2: Finger_2: Back_2: Hip_2: Knee_2: Ankle_2: Foot_2: Toes_2: undefined_22: Ribs_2: Face_2: Abdomen_2: Breast_2: Right_2: Left_2: Both_2: Work Related: Motor Vehicle Related: Date of Injury: Yes_2: No If Yes Dr: PATIENTS PLEASE COMPLETE THE ALL THE QUESTIONS BELOW THIS LINE: Yes_3: No If Yes Dr_2: undefined_23: Phone_3: Last Influenza Vaccination date: Last Pneumonia Vaccination date: If YES by Whom and When: Xray: CT Scan: Ultrasound: undefined_24: Other_5: If Yes list Where and When: If Yes list Date and Type: Who performed the surgery: Osteoarthritis: Heart Failure: Rheumatic Fever: COPD: AIDS: Cancer of: Hepatitis: Depression: Asthma: Anemia: Fractures: Pacemaker: Blood Clots: Heart Murmur: Emphysema: Sickle Cell: Paralysis: Other_6: Heart Attack: Stroke: Diabetes: HIV: Head injury: the: Osteomyelitis: High Blood Pressure: Chest PainAngina: Recurrent Bronchitis: Rheumatoid Arthritis: Tuberculosis Circle one: undefined_25: Have you ever been addicted or dependent on drugs or pain medicine: Every Day: Some Days: Never Smoker: Former Smoker: Quit in: Yes_5: No If YES beer alcoholic drinks wine Circle one: How much per month: SURGICAL HISTORY 1: SURGICAL HISTORY 2: Patient name_4: DOB_7: Bleeding Tendency: Blood Clot: Cancer: High Blood Pressure_2: Rheumatoid arthritis: Tuberculosis: Relative mother brother 1: Relative mother brother 2: Relative mother brother 3: Relative mother brother 4: Relative mother brother 5: Relative mother brother 6: Diabetes_2: Heart Attack_2: Heart disease: Osteoarthritis_2: Stroke_2: Depression_2: Relative mother brother 1_2: Relative mother brother 2_2: Relative mother brother 3_2: Relative mother brother 4_2: Relative mother brother 5_2: Relative mother brother 6_2: Rapid weight loss or gain: Night sweats: Numbness or tingling: Excessive bleeding: Vision changes: Other_7: Fever: Swollen ankles: Chest painangina: Taking blood thinners: Hearing loss: Active infection of: undefined_26: undefined_27: Jaundice: Palpitations: Weakness of arm or leg: Shortness of breath: Rash: Other_8: undefined_28: X: Check Box14: Check Box15: Check Box16: Check Box17: Check Box18: Check Box19: Check Box20: Check Box21: DATE: undefined_3: Employer: Other_2: undefined_4: MRI: Other_3: undefined_5: that a photocopy of this agreement shall be as valid as the original: organization has already taken action in reliance thereon: Parent: Spouse: Guardian: Other_4: I authorize release of billing medical information to: Detailed message: Detailed message regarding test results can be left on my answering machine: Date: Permission for Treatment Form_Patient_Name_Print: Permission for Treatment Form_Social_Security: Permission for Treatment Form_Witness: Permission for Treatment Form_Witness Relationship: Permission for Treatment Form_Date: Text70: Text71: Text72: Text73: Text74: Text75: Text76: Text77: Text78: Text79: Text80: Text81: Text82: Text83: Text84: Text85: Text86: Text87: Text88: Text89: Text90: Text91: Text92: Text93: Text94: Text95: Text96: Text97: Text98: Text99: Text100: Check Box102: Check Box103: Text104: Text105: Text106: