Loredo Hand Care Institute

Loredo Hand Care Institute

NEW PATIENT INFORMATION

GENERAL INFORMATION
Patient Name*

First NameLast Name
Date of birth:

MonthDayYear
SSN:
Driver’s License #:
State
Home#*
Mobile#
Email Address:*
Mailing Address:

Street Address

APT/UNIT

CityState / Province

Postal / Zip Code
Employer Name:
Address
Work Number:
Occupation
Person to notify in case of emergency:
Relationship
Contact#
Primary Care Physician:
Phone#
Pharmacy
City/Phone Number
How Did You Hear About Us?

FINANCIAL INFORMATION
Primary Insurance Co. (If no insurance, say "None" and skip to the next section.)*
Tel #
Insurance ID#
Group #
Insured’s Name
Insured’s Date of Birth

MonthDayYear
Date
Relationship to Patient
Secondary Insurance Co.
Tel #
Insurance ID#
Group #
Insured’s Name
Insured’s Date of Birth

MonthDayYear
Date
Relationship to Patient

ASSIGMENT AUTHORIZATION/OFFICE FEE POLICY
I hereby authorize
Loredo Hand Care Institute
I hereby authorize {iHereby} Loredo Hand Care Institute {loredoHand1028}, to release to my insurance company, any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such Medical care. I authorize and request my insurance company to pay directly to the doctor the amount due for my pending claim for medical services, by reason of such treatment or services rendered to me a photographic copy of this authorization shall be as the original. It is the policy of this office that the parent/guardian accompanying the child for reatment services will be responsible for all bills. We cannot bill the other parent. We respectfully request payment of any deductible, coinsurance and/or co-payment at the time the service is rendered regardless of insurance coverage. If any insurance payments are received by our office that is due to the patient, a refund will be made to the patient.
SIGNATURE*
Relationship to patient:
DATE

MonthDayYear
Date

HISTORY
Height
Weight
Drug Allergies:
Do You Drink Alcohol?

YesNo
Do You Smoke?

YesNo
Use Recreation Drugs?

YesNo
Do You Have Any Health Issues: (Please Circle)

High Blood PressureHigh CholesterolFibromyalgiaBreathing ProblemsDiabetesMigraine HeadachesKeloid ScarsShortness Of BreathDepression/Anxiety
Any Heart Issues:

Palpitations A-FibStentsHeart AttackHeart FluttersOther
Past Surgical History: (Please list name of all procedures and dates.)
Any Problems With Anesthesia?

Medications: (Prescription and Over the Counter Medications)

	List
1
2
3
4
5
6
7
8

REVIEW OF SYSTEM

General:

	Yes	No
Changes in weight
Progressive/Prolonged Fatigue

Gastrointestinal:

	Yes	No
Frequent Nausea / Vomiting
Abdominal pain

Infectious Disease:

	Yes	No
Fever
Night Sweats
Recent Infection

Pulmonary

	Yes	No
Cough
Shortness of breath
Wheeze
Snoring

Psychiatric:

	Yes	No
Suicidal thoughts
Hallucinations
Memory loss
Feeling depressed/anxious

Cardiac

	Yes	No
Do you ever wake up short of breath
Leg/ Ankle swelling
you sleep okay
Palpitations / Heart flutters
Abnormal sensation with exertion/ chest, arms, neck, back)

Gynecologic/Urologic:

	Yes	No
Incontinence
Difficulty / Painful urination
Blood in urine

Blood/Lymph:

	Yes	No
Easy bruising
Frequent nose bleeds
Swollen glands

Eyes:

	Yes	No
Blurred vision
Eye pain
Redness
Watering
Light sensitive
Dry feeling

Head and Neck:

	Yes	No
Decrease in hearing
Ringing in the ears
New Headaches
Sinus Problems
Sore throat
Changes in voice
Dry mouth

Skin:

	Yes	No
Changing moles
New rash
Tendency to form Keloid

Neurological:

	Yes	No
Dizziness
Difficulty walking
Sensory changes

Musculoskeletal:

	Yes	No
Weakness / Numbness
Neck / Back Pain
TMJ / Jaw Pain

ACKNOWLEDGEMENT
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform Loredo Hand Care Institute of any changes in my medical status. I also authorize the health care staff to perform the necessary services I may need.
Patient Name

First NameLast Name
Patient Signature*

Clear
Date

MonthDayYear
Date

HAND AND ELBOW HISTORY
Patient Name

First NameLast Name
DOB

MonthDayYear
Date
What Do You Do For A Living?
Which Hand/Arm Hurts?

RightLeftBoth
How Long Has It Been Going On?
What Gives You Issues? (Select All That Apply)

WristForearmHandThumbIndex FingerMiddle FingerRing FingerSmall FingerElbow
Do You Have Numbness And Tingling?

YesNo
How Severe Is Your Pain?

NoneMildModerateSevere
How Severe Is Your Weakness?:

NoneMildModerateSevere
Have you had any prior treatment for your condition?

YesNo

Have You Had An EMG/Nerve ?

YesNo
If So Where Was It Done At?

INSURANCE ACKNOWLEDGMENT, HIPPA & ENDORSEMENTS
Acknowledgment of Practice’s Notice of Privacy Practices:

I acknowledge that I was provided a copy of the Notice of Privacy Practices (NPP) and that I have read (or had the opportunity to read if I so chose) and understand the Notice of Privacy Practices (NPP) and agree to its terms. To file a complaint with Texas
Medical Board call 1-800-201-9353.

RECORDS RELEASE

I hereby authorize Loredo Hand Care Institute to furnish any medical records and/or other necessary information needed to process an insurance claim.

ASSIGNMENT OF BENEFITS

I, the undersigned, am the financially responsible party for the patient named above and agree to pay, in full, Loredo Hand Care Institute, for services rendered.

I accept Loredo Hand Care Institute fees as reasonable and customary.
Should your insurance deny payment for any and all services you are responsible for the amount billed.

NON-WORKMAN’S COMP DECLARATION

PLEASE READ - THE PHYSICIAN IS UNABLE TO DETERMINE WHETHER OR NOT THE SYMPTOMS YOU ARE SUFFERING ARE WORK-RELATED.

By signing below, you declare that you do not have a compensable work injury covered under a workman’s comp claim at this time. It is your responsibility as the patient to notify our office if you file a work compclaim. You also understand that should your workman’s comp claim be denied, you will be responsible for all balances in full. If group health insurance is available, we must receive a copy for processing as soon as you are aware the claim has been denied. This is not a guarantee that we accept your group insurance.

X-Ray & Ultrasound

I authorized Loredo Hand Care Institute to take x-rays and perform an ultrasound for my condition. I understand my x-rays and ultrasound and other pertinent information related to my treatment will be presented for analysis. I further understand this information is valuable in order to assist my doctor in his evaluation of an initial treatment plan, as well as modification to this plan during the course of treatment.
Patient Name

First NameLast Name
DOB

MonthDayYear
Date
Patient Signature*

Clear
Date

MonthDayYear
Date

OWNERSHIP AND REFERRAL DISCLOSURE FORM
Texas law requires a physician to disclose to a patient those arrangements permitted under applicable Texas law whereby such physician accepts remuneration to secure or solicit a patient or patronage for a person licensed, certified, or registered by a Texas health care regulatory agency. The purpose of this Disclosure is to notify you, the patient, that your attending physician(s) may receive remuneration for referring you to any of the following healthcare providers for certain healthcare services.

This Disclosure Form is designed to help ensure that patients have the necessary information to make an informed decision about their medical benefits and care. A physician must notify a patient that the physician has a direct financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient, and whether these are available elsewhere on a competitive basis; patients also should be informed whether provider to which they are referred are out of network. Patients shall be given a list of effective alternative resources, if any, that are reasonably available, informed that they have the option to use one of the alternative resources, and assured that they will not be treated differently by the physician if they choose an alternative provider or entity.

PATIENT REQUEST FOR AND CONSENT TO OUT OF NETWORK REFERRAL

I have the choice of using a participating health care facility/provider. If I choose to use a doctor or health care facility that does not participate in my network, my health insurance may not cover the services if my plan does not have out-of-network benefits. If my plan has out-of-network benefits, I understand that by using my out-of-network benefits I may have higher out-of-pocket costs that I will be responsible to pay. I hereby request and consent to my referral to the provider named above.

PHYSICIAN DISCLOSURE OF FINANCIAL INTEREST
- In compliance with the requirements of the law, you are being advised that I/we may have a direct financial interest in the diagnostic or treatment agency or in the non-routine goods or services that we may order for you.
- I/we may have a financial interest in the health care professional or health care facility that we take you to do surgery.
- I receive a medical directorship from Texas General Hospital, Crescent Medical Center.
- I am the medical director for IOM Hand (Neuromonitoring Company)
PATIENT ACKNOWLEDGMENT OF FINANCIAL INTEREST
- I have the choice to use a healthcare provider in which my physician does not have an ownership interest, provided such a healthcare provider is available. I wish to utilize a health care provider in which my physician has an ownership/investment interest, as described in this disclosure form.
- MY DISCLOSURES/INVOLVEMENT WITH SURGERY CENTERS/MEDICAL DIRECTORSHIP/ NEUROMONITORING DIRECTORSHIP/ INVESTMENTS OF SURGICAL CENTERS/ OTHER INVOLVEMENTS WERE ALL EXPLAINED TO THE PATIENT. ALL THEIR QUESTIONS AND CONCERNS WERE ADDRESSED. CHOICES WERE GIVEN TO THE PATIENT. THE PATIENT WANTED TO MOVE FORWARD WITH THE PLANNED TREATMENT.
Patient Name

First NameLast Name
DOB

MonthDayYear
Date
Patient signature*

Clear
Date

MonthDayYear
Date

SBT
Should be Empty:

	Yes	No	Did This Help?/ Describe
Anti-Inflammatory/ Pain Medications
Splints
Cortisone Injections
Physical Therapy
Chiropractic
Surgery
Other