Intake Form - Minivasive Pain & Orthopedics

Name(Required)

First Middle Last

Address(Required)

Street Address City State ZIP Code

Patient Date of Birth(Required)

Age(Required)

Gender

Social Security

Marital Status(Required)

Home Phone(Required)

Cell Phone(Required)

Email Address(Required)

Ethnicity

Non-Hispanic

Hispanic

Other

Race

Language Spoken

Occupation

Employer Name

Employer Address

Primary Care Physician

Phone

Referring Physician or Chiropractor

Phone

Preferred Pharmacy

Phone

Emergency Contact

Phone

Relationship to Patient

PRIMARY INSURANCE

Insurance Name

Phone

Insurance ID Number

Group Number

Address

Street Address City State ZIP Code

Name of Policy Holder

Date of Birth

SECONDARY INSURANCE

Insurance Name

Phone

Insurance ID Number

Group Number

Address

Street Address City State ZIP Code

Name of Policy Holder

Date of Birth

Signature of Patient/Guardian(Required)

Date(Required)

CONSENT TO TREAT: I consent to the administration of health care by Minivasive Pain & Orthopedics ("MPO"). I understand that I may set conditions or limitations on my treatment and care and that if I wish to provide such conditions, I will be given the opportunity to write those in a separate document. I have been informed and acknowledge that I may withdraw my consent at any time upon written notice to MPO. I am giving my consent to the administration of health care by MPO voluntarily, and that hereby knowingly and voluntarily enter into this Health Care Consent for Treatment. MPO is an interventional pain management clinic only. MPO encourages all patients to obtain a Primary Care Physician.

ASSIGNMENT OF BENEFITS: I hereby irrevocably assign to Minivasive Pain & Orthopedics ("MPO") any and all benefits and interest and rights, including the right to assert a lien or bring acause of action, under any insurance policies, benefit plans, indemnity plans, prepaid health plans, third-party liability policies, or from any other payer providing benefits on my behalf, for and to the extent of the services and goods provided to me by MPO. Under this assignment, MPO shall have an independent, non-exclusive right to appeal or pursue any denied or delayed claims on behalf of the insured or beneficiary. This assignment is not and shall not be construed as an obligation of MPO to pursue such interest and rights. By signing this form, I, as the patient or patient's legal representative, am directing any applicable health insurer, health benefit plan, indemnity plan, reinsurer, third-party liability insurer or other payer providing benefits on my behalf to pay MPO directly for the services and goods MPO provide to me. I understand that if insurance denies coverage or payment for services provided to me, I am financial responsibility for all charges.

IF MEDICARE or other similar government program should determine that I am not eligible for coverage or that the treatment is not covered, I will be responsible for payment, unless prohibited by law.

IF NO INSURANCE, THIRD-PARTY INSURANCE, or MOTOR VEHICLE ACCIDENTS you will be responsible for all charges associated with your care. We can file insurance claims to third-parties or insurance carriers on your behalf. You will be responsible for all charges as well as billing appropriate carriers as you like.

ACKNOWLEDGEMENT OF PRIVACY POLICIES/ HIPAA: I have been offered a copy of the Notice of Privacy Practices. The notice describes how my health information may be used or disclosed. I understand that I should read it carefully. I am aware that the notice may be changed at any time and I have the right to request new copies at any MPO location during regular business hours.

PHYSICIAN DISCLOSURE OF FINANCIAL INTEREST:: Texas law requires that your physician disclose to you any financial interest he or she may have in another healthcare entity to which you may be referred, so that you may address any concerns you may have directly with your physician. Your referring physician is a contractor and/or owner of Minivasive Pain & Orthopedics (the "Group"). The physician members of the Group are NOT owners of any of the Ambulatory Surgical Centers, Hospitals, Laboratories, or Imaging facilities to which you have been referred for therapeutic and/or diagnostic services. By signing the below, you acknowledge your receipt of this Physician Disclosure of Financial Interest.

By my signature below, I am acknowledging receipt of this document and agree to the terms under all sections of this document. Agreement Consent to Treat, Benefit Assignment and Financial Responsibility, Physician Disclosure of Financial Interest, and receipt of Privacy Policies/ HIPAA.

A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.

Signature of Patient/Guardian(Required)

Date(Required)

Relationship to Patient if signed by someone other than patient

HIPAA POLICY

According to the Texas State Law and per HIPAA policy, our practice is not allowed to release any of your information without your permission. Please list any individuals that you are giving permission to receive or to pick up any prescriptions written by the doctor.

Name

D.O.B.

Phone

Email

Relationship

Name

D.O.B.

Phone

Email

Relationship

CHECK ALL THAT APPLY

Phone

Okay to leave a message with detailed information

Leave message with call back number only

Email

Okay to send email with detailed information

I acknowledge that this authorization will remain in effect for up to one (1) year from the date of signature, unless I choose to revoke it earlier by submitting a written request to Minivasive Pain & Orthopedics.

Signature of Patient/Guardian(Required)

Date(Required)

If you have a pending insurance claim that must be resolved prior to your ability to pay for services rendered by our clinic or facility, we agree to temporarily defer collection actions. In consideration of such deferral, you expressly agree as follows:

You agree to toll and suspend any and all applicable statutes of limitations under Texas law, including but not limited to those under Texas Civil Practice and Remedies Code § 16.004(a)(3) (four-year limitation on debt actions), for the duration of the time your insurance claim remains unresolved, beginning from the date of service. The tolling period shall end thirty (30) days after the resolution of your insurance claim, whether by settlement, judgment, or other final disposition.

You agree to promptly notify your legal counsel, if any, of your outstanding balance with our clinic or facility. You further agree to direct your attorney to hold in constructive trust any proceeds from your insurance claim in an amount sufficient to satisfy your financial obligations to us. You also authorize us to communicate directly with your attorney regarding your account balance. Nothing in this agreement shall waive or prejudice our right to pursue legal remedies in the event of noncompliance.

Signature of Patient/Guardian(Required)

Date(Required)

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Intake Form - English

Patient Registration Sheet

PRIMARY INSURANCE

SECONDARY INSURANCE

NEW PATIENT FORM

HISTORY OF PRESENT ILLNESS

Mark on the diagram below where your pain is located. (Just tap/click and a dot will appear.)

PAST SURGICAL HISTORY

PAST MEDICAL HISTORY

FAMILY HISTORY

SOCIAL HISTORY

HOSPITALIZATION

HIPAA POLICY

CHECK ALL THAT APPLY

Deferred Payment Agreement

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

NAME OF PATIENT OR INDIVIDUAL