Intake Forms

Please provide us with the following information to ensure that your case is properly registered. If you need assistance completing these forms, please ask at the front desk.

Today's Date:

Patient's Name:

Preferred Name:

Street Address:

Social Security#:

Address

Cell Phone:

Marital Status:

Single Married Widowed Divorced

Home Phone:

Gender:

Male Female Other

Work Phone:

PIease designate one of the above numbers as your primary phone number by checking the box to the left.

Employer:

Who referred you to us?

Employer Street Address:

Family physician:

Employer Address

Phone number:

PRIMARY INSURANCE

Insurance Co. Name:

Primary Cardholder's Name:

Relation:

SociaI Security#:

Date of Birth:

Policy#:

Group#:

Claims Address:

City, State, Zip:

SECONDARY PAYOR/ RESPONSIBLE PARTY

Primary Cardholder's Name:

Insurance Co. Name:

Relation:

SociaI Security#:

Date of Birth:

Policy#:

Group#:

Claims Address:

City, State, Zip:

I the undersigned hereby authorize the staff to perform such services as deemed necessary by the physician to diagnose and treat my condition(s). Further I authorize assignment of my insurance rights and benefits directly to this provider and also authorize the release of such information as is needed to process insurance claims. I understand that I am responsible for all charges which may include legal fees, collection fees, or other expenses incurred by the provider in collecting my account. I hereby order all parties to accept a copy of this release and assignment in lieu of the original. This shall remain in effect until revoked by me in writing.

Patient Signature:

Date

Medical History

Last Name:

First Name:

Middle Name:

Birth Date:

Sex:

Height:

Weight:

Why are you seeing us today:

When did this problem begin?

Is this injury work related?

Is this injury because of an auto accident?

Allergies

What medications do you take? Please list name and dosage:

Name of your pharmacy:

Phone Number:

Do you smoke?

Ever smoke?

For How many years:

Past Surgical procedures:

Past Medical History

AIDS/HIV

Leg or Foot Ulcers.

Allergies/Hay Fever

Migraines.

Anxiety/Depression

Muscle, Joint or Bone Problems

Arthritis.

Neck Injury

Asthma.

Neurologic Disorder

Blood Clot.

Neuropathy

Cancer

Osteoporosis.

Carpal Tunnel.

Peripheral Vascular Disease.

Diabetes.

Pacemaker

Gout

Reflux/Gerd

Headaches

Rheumatoid Arthritis.

Hepatitis.

Seizures/Epilepsy

Hernia.

Stroke.

Hypertension.

Thyroid Problems.

Kidney Disease.

Ulcers.

Patient Signature

Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By my signature below I, acknowledge that I have read the Notice of Privacy Practices for Orthopedic Medicine of Alexandria, Ltd.

Signature of Patient

Signature of Parent (or personal representative)

If this acknowledgment is signed by a personal representative on behalf of the Patient, complete the following:

Personal Representative's Name:

Relationship to Patient:

I consent to reminder calls from Orthopedic Medicine of Alexandria:

Yes No

I consent to text messages from Orthopedic Medicine of Alexandria:

Yes No

For Office Use Only

I attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

○ Individual refused to sign

○ Communications barriers prohibited obtaining the acknowledgement

○ An emergency situation prevented us from obtaining acknowledgement

○ Other (Please Specify)

This form will be retained in your medical record.

ORTHOPEDIC MEDICINE OF ALEXANDRIA, LTD.
NOTICE OF PRIVACY PRACTlCES

The privacy of health information is important to us. We will maintain the privacy of your health information and we will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

A new federal law commonly known as HIPAA requires that we take additional steps to keep you informed about how we may use information that Is gathered in order to provide health care services to you. As part of this process, we are required to provide you with the attached Notice of Privacy Practices and to request that you sign the attached written acknowledgement that you have read this Notice. This Notice describes how we may use and disclose your protected health information to carry out treatment, payment ·or health care operations and for other purposes that are permitted .. or required by law. This Notice also describes your rights regarding health Information ;. we maintain about you and a_ brief description of how you may exercise these rights.

If you have any questions about this Notice: please talk to the Intake Coordinator or the Office Administrator. ..

NOTICE OF PRIVACY PRACTICES

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.

We are required by applicable federal and state law to maintain the privacy of your health Information. We are also required to allow you to read this Notice about our privacy practices, legal obligations, and your rights concerning your health Information (“Protected Health Information” or “PHI”.) We must follow the privacy practices that are described In this Notice (which may be amended from time to time).

For more Information about our privacy practices, or for a copy of this Notice, please contact us using the Information listed In Section II G of this notice.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
1. Permissible Uses and Disclosures without Your Written Authorization
  1. Treatment: We may use and disclose PHI for providing treatment, such as diagnosing and counseling services.
  2. Payment: PHI may be used or disclosed for billing and collection purposes, including actions taken by your health plan.
  3. Healthcare Operations: PHI may be used in connection with healthcare operations, quality improvement, training programs, accreditation, certification, licensing, or credentialing activities.
  4. Required or Permitted by Law: PHI may be used or disclosed as required or permitted by law, including disclosures for public health, oversight activities, judicial and law enforcement responses, research (approved by an Institutional Review Board), and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions.
  5. Office Operations: We may use your name in the office waiting room, leave voice messages, mail or fax billing statements or clinical reports, with the option for you to request restrictions for confidentiality.
2. Uses and Disclosures Requiring Your Written Authorization
  1. Progress Notes: Notes from counseling sessions will only be used by your clinician and will not be disclosed without your written authorization.
  2. Marketing Communications: Your health information will not be used for marketing communications without your written authorization.
  3. Other Uses and Disclosures: Any uses and disclosures not covered in Section I.A. will only be made with your written authorization. You can revoke such authorization at any time.
YOUR INDIVIDUAL RIGHTS
1. Right to Inspect and Copy: You may request access to your medical and billing records in writing, with the right to inspect and request copies.
2. Right to Alternative Communications: You can request alternative means of communication or locations for receiving PHI.
3. Right to Request Restrictions: You have the right to request a restriction on PHI used for disclosure for treatment, payment, or health care operations. You must request any such restriction in writing addressed to the Privacy Officer as indicated below. We are not required to agree with any such restriction you may request.
4. Right to Accounting of Disclosures: Upon written request, you may obtain an accounting of certain disclosures of PHI made by us.
5. Right to Request Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
6. Right to Obtain Notice: You have the right to obtain a paper copy of this Notice by submitting a request to the Privacy Officer at any time.
7. Questions and Complaints: If you desire further information about your privacy rights, or are concerned that we have violated your privacy rights, you may contact our Privacy Officer. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. We will not retaliate against you If you file a complaint with the Director or with our office.
CHANGES TO THIS NOTICE
1. Changes to this Notice: We may change the terms of this Notice at any time. If we change this Notice, we may make a new notice effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the revised notice in the reception area of our office. You may also obtain any revised notice by contacting the Privacy Officer.

INTAKE FORMS

PRIMARY INSURANCE

SECONDARY PAYOR/ RESPONSIBLE PARTY

Medical History

Past Medical History

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

For Office Use Only

ORTHOPEDIC MEDICINE OF ALEXANDRIA, LTD.
NOTICE OF PRIVACY PRACTlCES

NOTICE OF PRIVACY PRACTICES

John A. Bruno, Jr., MD
Board Certified Orthopedic Surgeon

PHONE

OFFICE TELEPHONE
HOURS

Monday – Friday
9:00 AM – 3:00 PM

INTAKE FORMS

PRIMARY INSURANCE

SECONDARY PAYOR/ RESPONSIBLE PARTY

Medical History

Past Medical History

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

For Office Use Only

ORTHOPEDIC MEDICINE OF ALEXANDRIA, LTD. NOTICE OF PRIVACY PRACTlCES

NOTICE OF PRIVACY PRACTICES

John A. Bruno, Jr., MD Board Certified Orthopedic Surgeon

PHONE

OFFICE TELEPHONE HOURS

Monday – Friday 9:00 AM – 3:00 PM

ORTHOPEDIC MEDICINE OF ALEXANDRIA, LTD.
NOTICE OF PRIVACY PRACTlCES

John A. Bruno, Jr., MD
Board Certified Orthopedic Surgeon

OFFICE TELEPHONE
HOURS

Monday – Friday
9:00 AM – 3:00 PM