new patient intake document - blossom pain management

Blossom Pain Management New Patient Intake Document - of 16

Blossom Pain Management801 Greenbrier Parkway • Suite B,

Chesapeake, VA 23320Phone: (757) 819-7547

Fax: (757) 842-6570

New Patient Intake Document

We invite you to discuss any questions you may have with us regarding our practice. Optimum healthcare is based on a friendly, mutual understanding between doctor and patient.

Patient Full Name

Step 1: All new patient information is registered in Electronic Medical Records

Step 2: All new patients are required to complete the New Patient Intake Forms.

Step 3: All new patients are required to bring picture identification, insurance cards and all medication bottles to their appointment.

Step 4: Records will be requested from the referring/previous treating physician(s).

Step 5: Patient examination, patient interview and patient evaluation will be performed by the physician extender (PA or NP) and/or MA and a Counselor. The patient interview is used as a tool to establish an accurate history for the patient, the one that reflects the role of physical, chemical and emotional stress on the patient’s health and well-being. Then the physician’s conclusions, based on the current objective data are reviewed with the patient, and are incorporated into the preliminary treatment plan.

Step 6: The doctor will advise the patient as to the need for additional procedures such as laboratory and x-ray tests. The Provider will advise the patient regarding follow-up and/or procedure scheduling.Typically, new patients are expected to be seen in follow up in one week, then every two weekstwice and every 4 weeks thereafter. Only compliant and stable patients may be seen less often.This may change based on each individual patient’s case and subjective conclusion of thetreating Provider.

Step 7: Most new practice patients will start receiving care after the doctor has fully evaluated all the examination results and derived a personalized care program. Your Pain Management program will begin at the time of your first visit as long as all the above is met and will continue as scheduled until maximum improvement can be achieved and maintained.

Step 8: In the event the new patient disagrees with the physician’s treatment plan/recommendations, the new patient will be provided with a “Letter of Refusal of Treatment.” There will be no refund of balances or copays.

Patient Signature Date

New Patient Intake Document - of 16Blossom Pain Management

REGISTRATION FORM

Today’s Date: PCP:

Last name: First name: Middle name:

SSN: Birth date: Age: Sex: M F

Marital Status: Single Married Divorced Separated Widowed

Please enter legal name if different: Former Name:

Street address: City: State: Zip:

P.O. box: City: State: Zip:

Occupation: Employer: Emp. Phone:

Choose clinic because/referred to clinic by(Please check one box):

Dr: Insurance Plan

Hospital

Family Friend Close to home/work Yellow pages Other

Other family members seen here:

GUARANTOR INFORMATION(Please give your insurance card to the receptionist)

Person responsible for bill: Home phone: Birth date:

Address (If different): City: State: Zip:

Occupation: Employer: Emp. Phone:

Employer address: Is this patient covered by insurance? Yes No

Primary insurance: Secondary insurance:

Subscriber’s name: SSN Birth date Group number Policy Number Co-payment

Patient Relationship to subscriber Self Spouse Child Other

Name of secondary insurance(if applicable):

Subscriber’s name: Group number Policy Number

Patient Relationship to subscriber Self Spouse Child Other

IN CASE OF EMERGENCYName of local friend or relative (not living at same address):

Relationship to patient: Home phone: Work phone:

Patient/Guardian signature Date

The information in this document is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Pain Management & Orthopedic Center or insurance company to release any information required to process my claims.

Mr. Mrs. Ms Miss Home phone no:



Fax: (757) 842-6570


Accident/Injury/Worker’s Compensation Form

Patient Name: Reference Date:

Date of Injury: Time of Injury:

Occupation: Supervisor:

Reported accident to:

Details of Accident:

Case Manager Name & Telephone:

Carrier:

Carrier Address: City: State: Zip Code:

Carrier Telephone:

Claim Number:

Contact Number:

Signature: Date:



Fax: (757) 842-6570


General Medical History

Date of Exam: Right-handed

Name: Employer:

Nickname: Years Employed:

DOB: Years of Education:

Age: PCP:

Height: Dentist:

Weight: Caregiver:

Current marital status: Pharmacy: Name, Address and Phone #

Married Single Divorced Widowed

Number of Children:

Social History:

Do you smoke? Yes No If so how much?

Do you drink alcohol? Yes No If so how much?

Have you ever had a problem with alcoholism? Yes No

Do you have any history of using Marijuana, Cocaine, Heroin, or other illegal drugs? Yes No

If yes which drugs?

Have you been treated for Psychological Problems? (i.e. depression, anxiety, panic attacks, chemical dependence) Yes No

If yes, when and where?

Race: Please choose from below

C Caucasian (White) I American Indian/Alaskan Native

B Black/African American J Native Hawaiian

A Asian E Other

G Native American M More than one race

F Asian Pacific American N1 Refused to report

P Pacific Islander N2 Don’t know

D Subcontinent Asian American N3 Not Ascertained

Ethnicity: Please choose from below

L Latino

O Other

N Not reported/refused

Left Handed



Fax: (757) 842-6570


General Medical History (continued)

Patient Name:

Past Medical History:

Do you have a history of any of the following?

Yes No Yes No

Chest Pain Stroke

Heart Attack Ulcer Disease

High Blood Pressure Diabetes

Congestive Heart Failure Thyroid Disease

Abnormal Heart Rhythm Anemia

Asthma Bleeding Disorders

Pneumonia Arthritis

Kidney Failure Psychiatric Disorders

Prostate Trouble Cancer

Liver Failure Seizures

Hepatitis Are You Pregnant?

Are you breastfeeding? Other

Past Surgical History:

Check this box if you have never had surgery

Please list any surgical procedures that you have had and the date of the surgery.

Surgical Procedure Date

Have you ever been hospitalized? Yes No

If yes, when and where?



Fax: (757) 842-6570



Patient Name:Current Medications:

Medication Amount How Often What is it for?

Please list any allergies:

Allergy Reaction

Family History: Please list any diseases that run in your family.(i.e. diabetes, heart disease, cancer, high blood pressure etc.)

Disease Family Member

Suicide

Mental Illness (no retardation)

Alcoholism

Medication (drug use disorder)

Cancer

Heart Attack (Prior to age 50)

Heart Disease

HTN

Early Deaths

Depression

Other

Please Check this box if you don't have allergies



Fax: (757) 842-6570


Patient Name:

Chief Complaint:

Please briefly state the main reason you are here today. For example: low back pain, headache, right Shoulder pain, etc.

History of Illness:When did your pain first start?

Describe how your pain started.

Was it the result of an accident or injury? Yes No

Are you involved in litigation (a lawsuit)? Yes No

Is Worker’s Compensation involved in injury? Yes No

Does the pain radiate from one part of your body to another area? Yes No

If yes, Where?

How do you best describe your pain? Dull ache Shooting Burning Sharp Throbbing

Other:

Do you have any of the following with your pain?

Tingling/numbness in the hands/feet Yes No

Weakness in the hands/feet Yes No

Pain radiating/traveling to arm/forearm/hands Yes No

Dragging the foot while walking Yes No

Difficulty holding bladder or bowel movement Yes No

Do you need to use any of the following to walk or for support since the pain started?

Cane Walker Crutches Braces

Which affect your pain? Mark B for better and W for worse. Leave blank if there is no effect.

Massage / rubbing Coughing Strong emotions Standing Sudden movements

Anxiety Getting out of bed Running Noise Heat

Sitting Bright light Cold weather Lying down Walking

Bending Vibration Ice Physical therapy Straining

Straining Wet climate Fatigue Reaching Lifting

Other



Fax: (757) 842-6570



Patient Name:

Have you had any of the following treatments and what was the result?

Treatment When Where Result

Physical Therapy

Nerve block/epidural

Exercise

TENS Unit

Traction

Acupuncture

Biofeedback

Braces

Medications

Relaxation training

Trigger point injections

Please rate your pain by choosing the one number that best describes your pain at its WORST in the last week. 100 1 2 3 4 5 6 7 8 9

No Pain Pain as bad as you can imagine

Please rate your pain by circling the one number that best describes your pain at its LEAST in the last week.0 1 2 3 4 5 6 7 8 9 10No Pain Pain as bad as you can imagine

On the diagram, shade in the areas where you hurt the most:



Fax: (757) 842-6570


Review of Systems

Review of Systems (Page 1 of 3)

Name: DOB: Date:

Please check all that apply:

Constitution (Health in General) No Problems Lack of energy Unexplained weight gain

Weight loss Loss of appetite Fever

Night sweats Pain in jaws when eating Scalp tenderness

Prior diagnosis of cancer Other:

Ears, Nose, Mouth & Throat No problems Difficulty with hearing Sinus problems

Runny nose Post-nasal drip Ringing in ears

Mouth sores Loose teeth Ear pain

Nosebleeds Sore throat Facial pain or numbness

Other:

C-V (Heart & Blood Vessels) No problems Irregular heartbeat Racing heart

Chest pains Swelling of feet or legs Pain in legs with walking

Other:

Resp. (Lungs & Breathing) No problems Shortness of breath Night sweats

Prolonged cough Wheezing Sputum production

Prior tuberculosis Pleurisy Oxygen at home

Coughing up blood Sore throat Abnormal chest x-rays

Other:



Fax: (757) 842-6570


Review of Systems Continued

Review of Systems (Page 2 of 3)

Patient Name:

Gastrointestinal (stomach & intestines) No problems Heartburn Constipation

Intolerance to certainFoods Diarrhea Abdominal pain

Difficulty swallowing Nausea Vomiting

Blood in stools Unexplained change in bowel habits Incontinence

Other:

Genitourinary System (Kidney & Bladder) No problems Painful urination Frequent urination

Urgency Prostate problems Bladder problems

Impotence Other:

Muscular System (Muscles, Bones, Joints) No problems Joint pain Aching muscles

Shoulder pain Swelling of joints Joint deformities

Back pain Other:

Integumentary (Skin, Hair & Breast) No problems Persistent rash Itching

New skin lesion Change in existing skin lesion Hair loss or increase

Breast changes Other:

Neurologic (Brain & Nerves) No problems Frequent headaches Double vision

Weakness Change in sensation Problems with walking or balance

Dizziness, Tremor Loss of consciousness

Uncontrolled motions Episodes of visual loss Other:



Fax: (757) 842-6570


Review of Systems Continued

Review of Systems (Page 3 of 3)Patient Name:

Psychiatric (Mood & Thinking) No problems Insomnia Irritability

Depression Anxiety Recurrent bad thoughts

Mood swings Hallucinations Compulsions

Other:

Endocrinologic (Glands) No problems Intolerance to heat or cold Menstrual irregularities,

Frequent hunger Frequent urination Frequent thirst

Changes in sex drive Other:

Hematologic (Blood/Lymph) No problems Easy bleeding Easy bruising

Anemia Abnormal blood tests Leukemia

Unexplained swollen areas Other:

Allergic/Immunologic No problems Seasonal allergies Hay fever symptoms

Itching Frequent infections Exposure to HIV

Other:



Fax: (757) 842-6570


SOAPP® Version 1.0 - SF

Review of Systems

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

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

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

How often have you used illegal drugs (for example, marijuana, cocaine, etc.) in the past five years? 0 1 2 3 4

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

Score:



Fax: (757) 842-6570



Fax: (757) 842-6570

Blossom Pain Management New Patient Intake Document - of 16

Patient Treatment Contract1. I understand that my provider and I will work together to find the most appropriate treatment for my chronic pain. I

understand the goals of treatment are not to eliminate pain, but to partially relieve my pain in order to improve myability to function. Chronic opioid therapy is only ONE part of my overall pain management plan.

2. I understand that my provider and I will continually evaluate the effect of opiates on achieving the treatment goalsand make changes as needed. I agree to take the medication at the dose and frequency prescribed by my provider.I agree not to increase the dose of opiate on my own and understand that doing so may lead to the treatment withopiates being stopped.

3. I understand that the common adverse effects of opioid therapy include constipation, nausea, sweating, anditchiness of the skin. Drowsiness may occur when starting opioid therapy or when increasing the dosage. I agree torefrain from driving a motor vehicle or operating dangerous machinery until such drowsiness disappears.

4. I will not seek opioid medications from another physician for the treatment of my chronic pain. Regular follow-upcare is required. Only my provider will prescribe opioid medications for my chronic pain and only at scheduledappointments.

5. I will attend all appointments, treatments, and consultations as requested by my providers. I will engage in othersupplemental treatments and follow any additional pain management recommendations.

6. I will not give or sell my medication(s)/ prescription(s) to anyone, including family members. I will not acceptany opioid medication(s) from anyone. I agree to be responsible for the secure storage of my medication(s)/prescription(s) at all times. If the medication(s)/ prescription(s) are stolen, I will report this to police and my providerand will produce a police report of this event if requested to do so.

7. I must disclose past medical history, past pain treatment, and any alcohol or drug addiction or dependency history.8. I hereby agree that my provider has the authority to discuss my pain management with other health care

professionals and my family members when it is deemed medically necessary in the provider’s judgment. If analternate provider becomes involved in my care due to an emergency situation or hospitalization, I will notify mydoctor ASAP so my care is properly coordinated and my condition adequately managed. Furthermore, I will furnishthe Treatment Facility visit note or Discharge Summary during my next visit.

9. I understand that if my prescription runs out early for any reason (for example, if I lose the medication or takemore than prescribed), my provider may not prescribe extra medication for me. I may have to wait until the nextprescription is due.*Note accepting a partial fill from your pharmacy means you are forfeiting the rest of yourmedication and it will not be replaced.

10. Opioid medication will only be available in written prescriptions during normal office hours.11. I understand that the use of other medications can cause adverse effects or interfere with opioid therapy. Therefore,

I agree to notify my provider of me using of any substances, including but not limited to sedatives, musclerelaxants, marijuana, alcohol, other medications not prescribed for me and all illicit drugs.

12. I agree to periodic unscheduled drug screens. In the event I am called for a Random Drug Screen I must report tothe office no later than in 72 hours and failure to do so could lead to my dismissal from the Practice.

13. I understand that I may become physically dependent on opioid medications, which in a small number of patientsmay lead to addiction. I agree that if necessary, I will permit referral to addiction specialists as a condition of mytreatment plan.

14. Any unused or unwanted opioid medications or Belbuca prescribed to me must be surrendered to the Blossomoffice for a proper disposal.

15. Any case of suspected or confirmed diversion of my medication will lead to immediate termination of treatment byBlossom Pain Management without appeal or recourse.

16. I understand that my failure to meet these requirements may result in my provider choosing to stop writing opioidprescriptions for me.

I acknowledge, understand and agree to all terms and conditions described in this Agreement

Patient Name: DOB:

Patient Signature: Date:

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PATIENT FINANCIAL POLICY

Pain Management & Orthopedic Center is dedicated to providing the best possible care for you, the patient. Please understand that payment for services is considered a part of your treatment. We respectfully ask that you read, agree to and sign this policy prior to any treatment rendered.

Co-pays and Balances:

The patient is expected to present a valid insurance card upon each visit. All co-payments and patient balances are due at the time of service unless arrangements have been made in advance. We accept cash, check and credit cards (Visa, MasterCard& Discover).

Participating Insurance Plans:

Your insurance policy is a contract between you and your insurance company; thus, it is legally binding for you to pay your quoted co-pay, deductible or co-insurance to the provider of treatment. As a participating provider with your insurance company, we have made a contract that we will file your medical claim in a timely manner as well as collect your co-payment, co-insurance and deductible per the standards of your policy.

Insurance Changes:

It is your responsibility to notify Pain Management & Orthopedic Center of any changes with your insurance company. You are fully financially responsible for payment to Pain Management if you have not updated your records with the correct billing information.

Referrals:

If you have an insurance policy that requires a referral from your Primary Care Physician (HMO) Gatekeeper policies, it is your responsibility to have a prior referral/authorization from your Primary Care Physician prior to your scheduled office visit in order to receive maximum benefits. If a referral/authorization has not been obtained at the time of service, you will be requested to either reschedule your appointment or pay for the visit at the time of service.

Self-Pay Accounts

Payment is required at the time of service for all services. Self-pay accounts are:

Patients without correct insurance information on file

Patients without an insurance card at the time of service

Patients who are covered by an insurance plan of which the practice does not participate

Non-Participating Plans:

The financial obligation of patients who are insured by carriers that Pain Management & Orthopedic Center does not participate will be considered as a self-pay account. It is the patient’s responsibility to know what providers are on the panels of their personal insurance.

I have read and understand Pain Management & Orthopedic Center’s financial policy and I fully agree to be bound by the terms stated above. Please sign and give back to receptionist. Thank You

Signature of Patient (or responsible party, if minor) Date:


HIPAA No ice of Privacy Prac ices5320 Providence Road Suite 100, Virginia Beach VA 23464

Phone: 757-962-2121 Fax:757-962-1911

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

TREATMENT:

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

PAYMENT:

Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

HEALTHCARE OPERATIONS:

We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to


object unless required by law. You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS

The following are statements of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information (fees may apply) – Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

You have the right to request a restriction of your protected health information – This means you may ask us not to use or disclose any part of your protected health information and by law we must comply when the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. By law, you may not request that we restrict the disclosure of your PHI for treatment purposes.

You have the right to request to receive confidential communications – You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You have the right to request an amendment to your protected health information – If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of all disclosures except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of this request.

You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.

COMPLAINTS

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

Please Sign Please note that by signing the Acknowledgment form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.

Signature Date:

*Caution - Reset clears all information

new patient intake document - blossom pain management

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