SVO NPReg

General Patient Information

We know your time is valuable, we appreciate your efforts in filling this out!
Patient Name*

First NameLast Name
What is your current gender identity? (Please check ALL that apply)*

MaleFemaleTransgender Male/Transman/FTMTransgender Female/Transwoman/MTFGender QueerDecline to answer
Patient Birth Date*

MonthDayYear
Phone Number*

Area CodePhone Number
Patient E-Mail Address*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Last 4 Social Security #*
(Important for insurance auth. etc.)
How did you hear about us? *
Primary Care Doctor, Address, Phone, Fax*
Referring Provider (if same as above, ignore)*
What Pharmacy do you prefer? (Name, address, phone number)*
Insurance Information

(if patient is a minor, please enter parent/guardian information)
Can we see your insurance card? FRONT
And BACK please.
Primary Insurance *
ID #*
Group #*
Subscriber's full name*
Subscriber address (if same as the patient, type "same")
Subscriber Date of Birth*
Secondary Insurance Information (if applicable)*
"None" if there is no secondary insurance
I hereby authorize my insurance benefits to be paid directly to Silicon Valley Orthopaedics. I understand I am financially responsible for non-covered services and balances remaining after insurance payment. I authorize Silicon Valley Orthopaedics to release any information required to process this claim.*

Patient or Guarantor Signature Clear
DateTime
What Brings You In?
Reason for visiting us here @ SVO:*
What's the story behind it? For example: How did it happen? When did it start? What activity makes it worse? What is your level of pain on average ? *
Occupation ('student' if in school)?*
Employer (which school if you are a student)?*
Is this visit as a result of a workplace injury?*

YESNO
If work related, what is the date of injury on your claim?
What treatments have you tried?*

IcePhysical TherapyAnti-Inflammatory or Pain MedicationsSurgeryCortisone InjectionChiropractic TreatmentAcupunctureActivity ModificationNothing
Have you had any diagnostic imaging of your injured body part? (X-Rays, MRI, CT Scan, etc.)*

Yes (please bring any disks, reports, and/or hard copies of images)No (no worries, we have X-Ray, MRI on site if needed)
Patient Medical History

(Sorry we have to ask... it's very helpful, and kind of important)
Patient Height (Feet.Inches)*
example 5.9
Patient Weight (lbs) *
Medical/Health History (ex. High Blood Pressure, Diabetes, Heart Failure)*
"none" if no medical history
Do you have a history of blood clots?*

YESNO
What about kidney disease/problems?*

YESNO
Please list any Surgeries/Operations (with rough dates if you can recall)*
"none" if no history of surgery
Please list ALL your Current Medications (a separate list is OK)*
"none" if no medications taken
Have you ever taken a bisphosphonate medication in the past i.e. Risedronate (Actonel), Alendronate (Fosamax), Ibandronate (Boniva), Zoledronic acid (Reclast), or Pamidronate (Aredia)? If so, which one and when did you stop? *
"none" if no medications taken
Any Allergies?*
Alcohol Consumption?*

I don't drink1-2 drinks/week1-2 drinks/day3+ drinks/dayother
Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/day
Please list any family medical history*

Review of System: Do you commonly experience any of these symptoms?*

	No	Yes
Immunology/Allergy: Seasonal allergies/hay fever, dermatitis, frequent itching, skin reactions, reactions to latex/rubber gloves, runny nose
General: Fever, fatigue, unexpected weight loss, weakness all over
Cardiovascular: Chest pain, heart palpitations, rapid heart beats, irregular heart beats, high blood pressure
Integumentary: Changes in skin color, skin rashes, skin masses, skin sores/ulcers, skin cancers
Endocrine: Frequent thirst, frequent hunger, hyperactivity, hypoactivity, growth changes, hair changes
Ears/Nose/Throat: Decreased hearing, ringing in the ears, dizziness, hoarseness, sinusitis
Hematology/Lymphatics: Bleeding tendency, easy bruising, lymph node enlargement, anemia
Gastroenterology: Abdominal pain, nausea, stomach ulcers/reflux, heartburn, indigestion, appetite change, change in bowel habits, diarrhea, constipation, loss of appetite
Musculoskeletal: Bone fractures, joint sprains, joint swelling, low back pain, joint stiffness, osteoarthritis, rheumatoid arthritis, fibromyalgia
Neurological: Headaches, speech difficulty, stroke/TIA, numbness, tingling, seizures, epilepsy, balance problems, falls
Eyes: Double vision, blurry vision, eye trauma, use of glasses/contacts
Psychiatric: Mood swings, sleep problems, depression, anxiety, substance abuse, heavy alcohol use/drinking
Respiratory: Shortness of breath, asthma, bronchitis, chronic lung problems, chronic cough
Genitourinary: Difficulty passing urine, incontinence, frequent urination, urinary tract infections, painful menstruation/PMS

For any "yes" symptoms above, please describe below *
Can we please have a selfie of you? (We're visual folks)*

Credit Card on File Policy

Dear Valued Patients,

Thank you for taking time to review our Credit Card on File Policy (CCOF). Our decision, here at Silicon Valley Orthopaedics (SVO), to execute this policy is based on optimizing our billing practices, providing more insurance transparency for you, and in turn improving your overall patient experience. With the ever-changing environment in healthcare, in particular the Affordable Care Act and High Deductible Plans (HDHPs), more of the financial responsibility is being shifted to the patient. Even after high deductibles have been met, most insurance carriers will only cover a portion of the total amount billed, which has led to an exponential increase in outstanding patient balances. Mailing out multiple statements for each individual patient encounter has proven to be demanding on resources and personnel. Adopting our Credit Card on File policy and implementing an electronic billing system i.e. electronically sending Explanation of Benefits (EOBs), bills, and receipts after each charge straight to your email, allows for our team to focus on improving quality of care and patient outcomes, as opposed to pursuing outstanding balances by mail.

Thank you very much for your understanding.

FAQs

Does this policy apply to everyone?

All patients with private/commercial insurance are required to keep a credit or debit card on-file. Once we receive the insurance explanation of benefits (EOB) for your visit, we will charge the credit card on file the exact amount as per the EOB that is stated to be patient responsibility. Once charged, we will email you a receipt of payment.

When do I have to pay for services?

Any time you receive medical care, you will be expected to pay in full for your services until your deductible is met and max out-of-pocket limit has been satisfied. If you have a large deductible (HDHP), you may have to pay out of pocket for your visits.

What is a Deductible and How Does It Affect Me?

An annual deductible is the dollar amount you must pay out of pocket during the year for medical expenses before your insurance coverage begins to pay.

For example, if your policy has a $2,000 deductible, you must pay the first $2,000 of medical expenses before the insurance company begins to pay for any services.

This works just like the deductible for your car insurance or homeowner’s insurance policy does.

When does a deductible begin?

Your deductible begins at the start of your plan year. Most plan years begin either January 1 or July 1, but plans can start on any date.

How will I know when my deductible has been met?

You can call your insurance company at any time to check on how much of your deductible has been met and some insurance companies have this information available online. Every time you receive medical services, you will receive notification from your insurance company with how much they paid or did not pay if the amount went to your deductible when they send you an Explanation of Benefits (EOB.)

But I always pay my bills, why me?

We need to be consistent and apply a universal policy to all patients. We have wonderful patients and we know that most of you pay your balances. Unfortunately, this is not always the case.

How will I know how much you are going to charge me?

You will receive a letter in the mail (or e-mail) from your Insurance carrier that explains how much of your office visit they pay and how much you pay. This is called an Explanation of Benefits (EOB.) This letter tells you exactly, according to your health insurance coverage, how much of your health care bill is your responsibility and how much is the responsibility of your insurance to pay.

Then what?

We receive the same Explanation of Benefits (EOB) that you do. Most Insurances will send your EOB prior to us receiving our copy. It arrives about 10-20 days after your appointment has been billed. We look at each EOB carefully and determine what your insurance has determined as patient responsibility. This is the same way we normally determine how much to send you a statement for in the mail.

When do I give you my credit card?

At your next transaction, we will swipe your debit/credit card with an encrypted reader that will securely upload your credit card number into the Onstaff and return the card to you. With the encrypted reader, we will never see all the numbers of your credit card. You can deliver your credit card information over the phone or by mail, but the most secure way is in person through the encrypted reader.

My High-Deductible Health Plan has a Health Savings Account (HSA) Card. Can I keep my HSA card on file?

Yes, you can keep your HSA card on file, however, we will require an additional card to be kept on file should the funds in your HSA account become insufficient.

What if I need to dispute my bill?

We will always work with you to understand if there has been a mistake. We will refund your credit card if we or your insurance company has made a billing error. We will only charge the amount that we are instructed to by your insurance carrier as shown in the EOB they send to us. This is the same way we determine how much to send you a bill for in the mail.

What if I have more questions?

Our friendly billing professionals are happy to speak with you about your account.

Cancellation / No Show Policy

Thank you for visiting us at Silicon Valey Orthopaedics. Should you need to cancel or reschedule an appointment please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment. Please see our Appointment Cancellation/No Show Policy below:

Effective June 1, 2021 any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show and charged a $50.00 fee.

Any established patient who fails to show or cancels/reschedules an appointment with no 24 hour notice a second time will be charged a $75.00 fee.

If a third No Show or cancellation/reschedule with no 24 hour notice should occur the patient may be dismissed from Silicon Valley Orthopaedics.

Any new patient who fails to show for their initial visit will not be rescheduled.

The fee will be charged to the patient, not the insurance company, and we will inform you that your credit card on file will be charged.
We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our Office Manager.
Name*

First NameLast Name
Email Address*
example@example.com
By signing below, I agree to the above CCOF/No-Show policy and consent to allow SVO to charge and keep my credit card on file.*

Clear
DateTime

NARCOTIC PRESCRIPTION POLICY
Thank you for helping us fight the Opioid Epidemic

Pain Management Controlled Substances Contract

The purpose of this agreement is to create an understanding regarding controlled substances (a type of medication that is regulated by states and the Federal government) that may benefit your pain symptoms. My goal is to treat you as safely with these potent medications and also prevent abuse of or addiction to these medications. Medications such as opioids (narcotic analgesics), benzodiazepine tranquilizers, barbiturate sedatives, and muscle relaxants such as Soma (carisoprodol), that may be useful in managing pain, can be problematic in several ways. These medications have “street value” and potential for abuse. Although these medications may be prescribed with the goal of improving your comfort and functionality, their medical use is also associated with the risk of serious adverse effects such as development of an addiction disorder or a relapse in a person with a prior addiction history. The extent of this risk is uncertain, but it is known to be higher in certain vulnerable patients. My goal is to have you take the lowest possible dose of medication that is reasonably effective in managing your pain and improving your function and when possible have it tapered and eventually discontinued while at the same time monitoring and managing these potential risks.

Because these medications have the potential for abuse or diversion (i.e. sharing, trading, or selling to ANYONE other then whose name is on the prescription), strict accountability is necessary for both medical safety and legal reasons. Therefore, the following policies are agreed to by you, the patient, to help me keep you safe and to provide you with good care.

1. This contract is based on post operative pain management for the first three months post op. Pain requiring narcotics beyond three months will result in a referral to Pain Management Specialist. If a pain specialist can not be established, progressive reduction of pain medications will occur with each refill until tapered off completely.

2.     You must get a prescription for all controlled substances from the physician whose name appears below or, during his or her absence, by the covering physician, unless specific written authorization is obtained for an exception. (Multiple sources can lead to untoward medication interactions or poor coordination of treatment.)

3.     You must obtain all controlled substances from the same pharmacy. Should the need arise to change pharmacies, our office must be informed.

4.     You must inform our office of any new medications or medical conditions and of any adverse effects you experience from any of the mediations that you take.

5.     You must give the prescribing physician permission to discuss all diagnostic and treatment details with dispensing pharmacists or other professionals who provide your health care for purposes of maintaining accountability and coordinating your care.

6.     You may not share, sell or otherwise permit others to have access to these medications. You must take all mediations exactly as prescribed, unless you develop side effects. If you develop side effects, you must consult with your doctor or local emergency providers.

7.     You must not stop these medications abruptly or without consulting the prescribing physician as an abstinence/withdrawal syndrome may develop.

8.     You must agree that your urine may be tested for controlled substances before initiation of therapy and that random urine follow up testing may be done. You must cooperate in such testing, and you must agree that the presence unauthorized substances, illicit substances or absence of prescribed medications may prompt referral for assessment for addictive disorder and possible tapering and discontinuation of the controlled substances immediately or in the future.

9.     You will not give your prescriptions or bottles of these medications to anyone else. These substances may be sought by other individuals with chemical dependency and should be closely safeguarded. You will take the highest degree of care with your medications and prescriptions. You will not leave them where others might see or otherwise have access to them.

10. You must bring original containers of medication to each office visit.

11. You must keep all controlled substances in a secure area. Since the medications may be hazardous or lethal to a person who is not tolerant to their effects, especially a child, you must keep them out of reach of such people.

12. You must exercise extreme caution when taking these medications and driving or operating heavy machinery. The use of these medications may induce drowsiness or change your mental abilities, thereby making it unsafe to drive or operate heavy machinery. The effects of these medications are particularly problematic during any dose changes. If you are the slightest bit impaired, you must refrain from these activities.

13. You must discuss the long term use of controlled substances with you physician. Prolonged opiod use can be associated with serious health risks. You need to understand these risks.

14. You must agree that mediations will not be replaced if they are lost, flushed down the toilet, destroyed, left on an airplane etc. If your medication has been stolen and you complete a police report regarding the theft and present that report the prescribing physician, an exception may be made at the discretion of your treating physician.

15. You must agree that easy refills will not be given.

16. You understand that prescriptions may be issued early only if the physician or patient will be out of town when a refill is due. These prescriptions will contain instructions to the pharmacists that they are not to be filled prior to the appropriate date.

17. You agree that if the responsible legal authorities have questions concerning your treatment, as might occur, for example if you were obtaining medications at several pharmacies, all confidentiality is waived and these authorities may be given full access to our records of controlled substances administration.

18. You agree that failure to adhere to these polices may result in tapering and cessation of therapy with controlled substance prescribing by these physician or referral for further specialty assessment.

19. You agree that prescription renewals are contingent on keeping scheduled appointments. Do not phone for prescriptions after hours or on weekends. If you receive any controlled substances in the ER, you must report that incident to your prescriber, in writing within 48 hours.

20. You recognize that any medical treatment is a trial and that continued prescription is contingent on evidence of benefit and improved functionality.

21. You acknowledge that the risks and potential benefits of therapy with controlled substances have been explained to you and that you have had the opportunity to ask any questions that you may have.

22. You understand and agree that failure to adhere to these policies will be considered noncompliance and many result in cessation of opioid prescribing by your physician and possible dismissal from this clinic.

23. You affirm that you have full right and power to sing and be bound by this agreement. You further affirm that you have been given the opportunity to ask any questions you may have and that you have read, understand, and accept all of its terms.
Name*

First NameLast Name
By signing below, I have read and agree to the above Narcotic Prescription Policy.*

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DateTime

Notice of Acknowledgement of Receipt and Understanding

Notice To Patients

Medical doctors are licensed and regulated by the Medical Board of California.

To check up on a license or file a complaint go to: www.mbc.ca.gov

email: licensecheck@mbc.ca.gov or call (800) 633-2322.
Name*

First NameLast Name
By signing below, I confirm I read the Notice of Acknowledgement of Receipt and Understanding.*

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DateTime
Should be Empty:

General Patient Information

Insurance Information

What Brings You In?

Patient Medical History