Intake Form - Minivasive Pain & Orthopedics

PATIENT REGISTRATION SHEET

Please complete the ENTIRE form and sign where indicated.
Please provide the receptionist with your insurance card (if applicable).

Last Name:

First Name:

MI:

Address:
City:
State:
Zip Code:

Date of Birth:
Age:
Gender:
Social Security:
Marital Status:
Home Phone:
Cell Phone:
Email Address:

Ethnicity:
Non-HispanicHispanicOther
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:
City:
State:
Zip Code:
Name of Policy Holder:
Date of Birth:

Secondary Insurance

Insurance Name:
Phone:

Insurance ID Number:
Group Number:

Address:
City:
State:
Zip Code:
Name of Policy Holder:
Date of Birth:

Signature of Patient/Guardian

Date

Page 1 of 7

NEW PATIENT FORM

History of Present Illness

Occupation:

When did your pain start?

Where is your pain? (check all that apply)
NeckBackArmLegOther

Rate your pain
SEVEREMODERATELY SEVEREMODERATEMILD

What is the date of injury (if applicable)?

What caused your pain?
MOTOR VEHICLE ACCIDENTWORK RELATEDSPORTSLIP OR FALLOTHER

Describe the inciting event that caused pain (if applicable)
DRIVERPASSENGEROTHER

Describe your pain
SHOOTINGTHROBBINGACHINGBURNINGSHARPDULLCRAMPINGOTHER

Is the pain constant?
YesNo

How does your current condition affect your ability to perform daily activitites (such as bathing, dressing, cooking, driving, working or other routine tasks)?
SEVERE IMPACTMODERATE IMPACTMILD IMPACT

What makes your pain worse? (check all that apply)
SITTINGSTANDINGWALKINGBENDINGCOUGH & SNEEZELYING DOWNOTHER

What makes your pain better? (check all that apply)
RESTICE/HEATNOTHINGOTHER

Have you ever received care from a Chiropractor or Physical Therapist?
YesNo

When?
With who?

Have you been treated by a previous Pain Specialist?
YesNo

When?
By who?

Curent Occupation:

Mark on the diagram above where your pain is located. (Just click at the area and a dot will appear.)

Medication

List all the medication you have tried for your pain:

Allergies

List all known allergies:

INITIAL

Page 2 of 7

Past Surgical History

List all known surgeries.

Date:

Past Medical History

Please list all DIAGNOSED conditions:

Family History

Check all appropriate diagnoses as they pertain to your family history.

No significant family historyDiabetesCancerHypertension

Social History

Are you capable of becoming pregnant?
YesNo

If so, are you currently pregnant?
YesNo

Alcohol Use (check all that apply):

Current AlcoholismHistory of AlcoholismSocial Alcohol UseNever Drinks AlcoholDaily limited Alcohol Use

Tobacco Use (check all that apply):

Current tobacco userFormer tobacco userNever used tobaccoChewing tobaccoE-Cigarette/Vape

Illicit Drug Use (check all that apply):

Denies any illicit drug useCurrently using illicit drugs

Hospitalization

Please list any recent hospitalizations:

Month/Year:

Reason:

Hospital:

Month/Year:

Reason:

Hospital:

Month/Year:

Reason:

Hospital:

INITIAL

Page 3 of 7

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

Date

Relationship to Patient if signed by someone other than patient

Page 4 of 7

HIPAA Policy

According to the Texas State Law and per HIPPA 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. Please list any individuals that you are giving permission to receive information in regards to you as a patient at our practice.

Name

D.O.B.

Phone

Relationship

Name

D.O.B.

Phone

Relationship

CHECK ALL THAT APPLY

Phone

Okay to leave a message with detailed informationLeave 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

Date

Page 5 of 7

Deferred Payment Agreement

MEDICAL PROVIDER: Minivasive Pain & Orthopedics, PLLC

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

Date

Page 6 of 7

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

Developed for Texas Health & Safety Code § 181.154(d)
effective June 2013

Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information. Covered entities as that term is defined by HIPAA and Texas Health & Safety Code § 181.001 must obtain a signed authorization from the individual or the individual's legally authorized representative to electronically disclose that individual's protected health information. Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law. Covered entities may use this form or any other form that complies with HIPAA, the Texas Medical Privacy Act, and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.

NAME OF PATIENT OR INDIVIDUAL

Last

First

Middle

OTHER NAME(S) USED

DATE OF BIRTH

Month Day Year

ADDRESS

CITY

STATE

ZIP

PHONE

ALT. PHONE

EMAIL ADDRESS (Optional)

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL'S PROTECTED HEALTH INFORMATION:

Person/Organization Name
Address

City

State

Zip

Phone

Fax

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

Person/Organization Name
Address

City

State

Zip

Phone

Fax

REASON FOR DISCLOSURE

(Choose all that apply)

Treatment/Continuing Medical CarePersonal UseBilling or ClaimsInsuranceLegal PurposesDisability DeterminationSchoolEmploymentOther:

WHAT INFORMATION CAN BE DISCLOSED?

Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first box.

All health informationPhysician's OrdersProgress NotesPathology ReportsHistory/Physical ExamPatient AllergiesDischarge SummaryBilling InformationPast/Present MedicationsOperation ReportsDiagnostic Test ReportsRadiology Reports & ImagesLab ResultsConsultation ReportsEKG/Cardiology ReportsOther:

Your initials are required to release the following information:

Mental Health Records (excluding psychotherapy notes)

Drug, Alcohol, or Substance Abuse Records

Genetic Information (including Genetic Test Results)

HIV/AIDS Test Results/Treatment

EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reaching the age of majority; or permission is withdrawn; or the following specific date (optional): Month Day Year

RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under "WHO CAN RECEIVE AND USE THE HEALTH INFORMATION." I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code 181.154(c) and/or 45 C.F.R. 164.502(a)(1). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.

Signature of Individual or Individual's Legally Authorized Representative

Date

Printed Name of Legally Authorized Representative (if applicable)

If representative, specify relationship to the individual:
Parent of MinorGuardianOther:

A minor individual's signature is required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment (See, e.g., Tex. Fam. Code 32.003).

Signature of Minor Individual

Date

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