Welcome
to University Orthopedics!
Before you come into the office for
your appointment with Dr Husain,
it is essential that you:
A)
Get any Xrays taken (If
required)
B) Fill out All paperwork
*Waiting to take xrays or filling out paperwork the day of your appointment
will result in extremely long wait times.
Also be sure to bring your insurance card along with a photo i.d. And be sure to have either a check, cash or
credit card for your co pay, co insurance of deductible payment. They are due
at the time of your appointment.
Thank you!
In
order for us to better serve you, please fill out the
enclosed questionnaire and bring with you on the date
of
your scheduled appointment. An Orthopedic assistant
will phone you before your appt date to obtain your medical history.
This
information is required to be seen by Dr Husain.
Appt date:_____________Time:____________a.m./p.m.
Reminder:
Please bring:
1.
Any X-Rays AND MRI films that were taken of the injured body part that
you are seeing Dr Husain for.
2.
Your Medical Insurance Card and Picture ID.
(Although we are
contracted with most PPO insurances, we urge you to telephone the member
services number on your insurance card to inquire as to our contract status
with your insurance plan.)
3.
Form of payment for any co-payments or deductibles due.
(Deductible
and co-payments are due in full at the time of service. No exceptions. We
accept checks, Cash, Visa and Master card.)
CANCELLATION
POLICY
If for any reason you are unable to keep your
scheduled appointment, please notify our office within a 24hr period prior to
your appointment time to avoid a $20 no show fee by calling (909) 989-4400.
Thank you,
University Orthopedics.
(Please
Print & Complete In Full)
Patient’s
Last Name:__________________________________
First Name: ________________________________MI:______
Patient’s Date of Birth:
_________________ Age: _______ Sex:_______ Social Security
#:_____________________________
Mailing Address:
Home Phone #-( )____________________Cell Phone
#-( )______________________Fax
#-( )____________________
Drivers License #:
_______________________________Email Address: ______________________@____________________
(Check the following that applies
to the patient)
Martial Status: ____Single ____Married ____Divorced ____Widowed
Employed: ____Full Time ____Part Time ____Retired ____Unemployed
Student: ____Full
Time ____Part Time ____Not a Student
Patient Employer:
__________________________________________ Phone#-( )_________________________Ext:________
Patient Employer Address, City,
State, Zip Code:
_________________________________________________________________
Spouse or Parent Name (circle one)______________________________DOB:_______________S.S.#________________________
Spouse
or Parent Employer________________________________________________Work Phone
#-( )___________________
Family
Physician:_________________________________________ Phone
#_____________________Fax#_________________
Emergency Contact, and
Relation:____________________________________ Phone #-( )______________________________
Name of Doctor / Facility
/ Source, who referred you: __________________________________
Phone #:_____________________
If not referred, how did you hear
about us?__________________________________________________________________
* REASON FOR SEEING DOCTOR/SYMPTOMS________________________________
DATE OF INJURY/ONSET: __________
Was injury sustained on the
Job? Y or N If yes, was this filed with your employer as
Worker Compensation? Y or N If yes, what is the claim #?
_______________________________Adjustor’s
Name:___________________________________________
Adjustor’s Phone #-( )__________________________________ Fax #-(
)_________________________________________
HEALTH INSURANCE INFORMATION
Patient Relationship to
Subscriber: (circle one) ____SELF ____SPOUSE ____CHILD _________________OTHER
* Primary Insurance Company:
_____________________________________________________________________________
Policyholder Name:
_______________________________Policyholder
DOB:_________________S.S.#____________________
* Secondary Insurance Company: ___________________________________________________________________________
Policyholder Name:
_______________________________Policyholder
DOB:_________________S.S.#____________________
CONSENT FOR TREATMENT
I, the
undersigned, whose name appears above, hereby consent to and authorize all
diagnostic and therapeutic treatments considered necessary or advisable in the
judgment of Asghar Husain , MD
PATIENT SIGNATURE:
_______________________________________________________DATE:
_____________________
(If
a minor, this form must be signed by parent or legal guardian) PLEASE INDICATE OF DIFFERENT LAST NAME
NOTICE OF PRIVACY POLICIES AND PRACTICES FOR
UNIVERSITY ORTHOPEDICS
Dear
Patient:
This
notice describes how information about you may be used and disclosed and how
you can get access to this information.
Please review it carefully.
INTRODUCTION
At University Orthopedics, we are committed to treating
and using protected health information about you responsibly. This Notice describes the personal
information we collect, and how and when we use or disclose that
information. It also describes your
rights as they relate to your protected health information. This Notice is effective
UNDERSTANDING
YOUR MEDICAL RECORD/HEALTH INFORMATION
Each
time you visit University Orthopedics; a record of your visit is made. Typically, this record contains information
about your visit including your examination, diagnosis, test results, treatment
as well as other pertinent healthcare data.
This information, often referred to as your health or medical record,
serves as a:
- Basis for planning your
care and treatment
- Means of communication
with other health professionals involved in your care
- Legal document
outlining and describing the care you received
- A tool that you, or
another payer (your insurance company) will use to verify that services
were actually provided.
- An education tool for
medical health providers
- A source for medical
research
- Basis
for public health officials who might use this information to assess
and/or improve state as well as national healthcare standards
- A source of data for
planning and/or marketing
- A tool that we can
reference to ensure the highest quality of care and patient satisfaction
Understanding
what is in your record and how your health information is used helps you to
ensure it’s accuracy, determine what entities have access to your health
information and make informed decisions when authorizing the disclosure of this
information to other individuals.
YOUR RIGHTS
You
have certain rights under the federal privacy standards. These include:
- The right to request
restrictions on the use and disclosure of your protected health
information
- The right to receive
confidential communications concerning your medical condition and
treatment
- The right to inspect
and copy your protected health information
- The right to amend or
submit corrections to your protected health information
- The right to receive
accounting of how and to whom your protected health information has been
disclosed
- The right to receive a
printed copy of this notice
OUR
RESPONSIBILITIES
University
Orthopedics is required to:
- Maintain the privacy of
your health information
- Provide
you with this Notice as to our legal duties and privacy practices with
respect to information we collect and maintain about you
- Abide by the terms of
this notice
- Notify you if we are
unable to agree to a requested restriction
- Accommodate
reasonable requests you may have regarding communication of health
information via alternative means/locations.
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies practices will be applied to all protected health information we maintain. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according procedures included in the authorization.
HOW WE MAY USE AND/OR DISCLOSE YOUR HEALTH INFORMATION
We
will use your health information for treatment. Your health information may be
used by staff members or disclosed to other health care professionals for the
purpose of evaluating your health, diagnosing medical conditions and providing
treatment. For example: results of laboratory tests and procedures
will be available in your medical record to all health professionals who may
provide treatment or who may be consulted by staff members.
We
will use your information for payment.
Your
health plan may request and receive information on dates of service, the
services provided, the medical condition being treated in order to pay for the
service rendered to you.
We
will use your information for regular health operations.
Your
health information may be used as necessary to support the day-to –day
activities and management of University Orthopedics. For example: information on the services you
received may be used to support budgeting and financial reporting, and
activities to evaluate and promote quality.
Business
Associates.
In
some instances, we have contracted separate entities to provide services for
us. These “associates” require your
health information in order to accomplish the tasks that we ask them to
provide. Some examples of these
“business associates” might be a billing service, collection agency, answering
services and computer software/hardware provider.
Communication
with Family.
Due
to the nature of our field, we will use our best judgment when disclosing
health information to a family member, other relatives or any other person that
is involved in your care that you have authorized to receive this
information. Please inform us when you
do not wish a family member or other individual to have authorization to
receive your information.
Research/Teaching/Training.
We
may use your information for the purpose of research, teaching and training.
Healthcare
Oversight.
Federal
Law requires us to release your information to an appropriate health oversight
agency, public health authority or attorney, or other federal/state appointee
if there are circumstances that require us to do so.
Public
Health Reporting.
Your
health information may be disclosed to public health agencies as required by
law.
Law
Enforcement
Your
health information may be disclosed to law enforcement agencies, without your
permission, to support government audits and inspections, to facilitate
law-enforcement investigations and to comply with the government mandated
reporting.
Appointment
reminders
We
may use your information to remind you about your upcoming appointments.
Typically,
these are left by phone and may be left as a message on your answering
machine. If you don’t approve of this
method, you must inform us in writing.
Other
uses and disclosures
Disclosure
of your health information or its use for any purpose other than those listed
above requires your specific authorization.
If you change your mind after authorizing a use or disclosure of your
information, you may submit a written revocation of the authorization. However, your decision to revoke the
authorization will not affect or undo any use or disclosure of information that
occurred before you notified us of your decision.
FOR MORE
INFORMATION OR TO REPORT A PROBLEM
If
you have complaints, questions or would like additional information regarding
this notice or the privacy practices of University Orthopedics, please contact:
Leslie
Fletcher
University
Orthopedics
7777B
(909)
989-4400
CONSENT FOR TREATMENT
I, the undersigned, hereby consent to and authorize all
diagnostic and therapeutic treatments considered necessary or advisable in the
judgment of
Patient Signature_______________________________ Date_________________
(If a minor, must be signed by legal parent or guardian)
ASSIGNMENT OF
BENEFITS/FINANCIAL RESPONSIBILITY
I, hereby authorize
Patient Signature___________________________________ Date_____________
(If a minor, must be signed by legal parent or guardian)
AUTHORIZATION FOR RELEASE OF
INFORMATION
I give the office of Dr
I understand that if a hospital or physician or family member or spouse calls for any information and the name is not listed above, the office will be unable to release any information.
Patient Signature___________________________________ Date________________
(If a minor, must be signed by legal parent or guardian)
UNIVERSITY ORTHOPEDICS NOTICE
OF PRIVACY POLICIES
I ____________________(print name) have received and read the University Orthopedics Notice of Privacy Polices and Practices. (If receiving paperwork in hand or online the privacy policy is on a separate page)
Patient Signature____________________________________Date_________________
(If a minor, must be signed by legal parent or guardian)
There is a $25 fee for any appointments
that are not cancelled within 24 hours prior to your appointment. These are
considered “no shows.”
Please sign below to indicate you have
read our $25 fee no show policy.
Thank you.
Signed_______________________________
Date________________