Patient Information
Name
*
First Name
Middle Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
Other
Email
*
example@example.com
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Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Health Insurance Name
*
Insurance Policy ID
*
Insurance Package/Type
*
Medical Data
Primary Insurance Phone No
*
Where do you have pain?
*
HIP
Ankle Foot
Cervical, Collar (Neck)
Lower Back
Shoulder
Wrist Hand
Elbow
Other
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Have you received a brace in last 5 years?
*
Yes
No
What is your Height , Weight and Waist?
*
Height
Weight
Waist
In a Scale of 1 to 10 how do you rate your pain level on a bad day?
*
1
2
3
4
5
6
7
8
9
10
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Do you Have Diabetics?
*
Yes
No
Do you take Insulin?
*
Yes
No
How many times do you check your sugar level a day?
*
Once in a day
Twice in a day
Never
Acknowledgment, Authorization and Waiver
Costume acknowledges receipt/proof of delivery of the following: I confirm on this day I received from Pain Management Center the product listed above and participated in the plan of care. I have also been provided a separate patient handout with the following: (1) information and instruction regarding proper use and care of the product: (2) Medicare Supplier Standard: (3) Patient Bill of Right: (4) Proper instruction for use care and Maintenance of product provided: (5) Provider's Notice of privacy practices: (6) warranty information: and (7) Contact information for question and /or complaints. Consent Treatment: I consent to treatment by the provider I understand and acknowledge that (1) my care is under the supervision and control of my attending physician: (2) my physician as prescribed the product and services notes as part of my treatment and has explained to me its risks advantages, possible complications and alternatives, and why it is considered necessary treatment for my condition: (3) The provider's services do not include diagnostic, prescriptive or other functions pertaining to licensed physicians and (4) my physicians is solely responsible for diagnosing and prescribing drugs, product, and therapy for my condition and otherwise supervising and controlling my medical condition. I further understand I may refuse to accept delivery of the product. Assignment of Benefits, Consent to Bill and Release of Medical information: I consent to billing by the provider and request that the payment of authorized Medicare, Medicaid, well care, Aetna and/or other third-party instance benefits, including supplemental Co-insurance and Medigap policies is made on my behalf directly to the provider for the product sold to me by the provider and identified below. I agree to provide all documents and information necessary for the provider to obtain direct payment from Medicare, Medicaid, well care, Aetna or other third-party payers and hereby authorize the release of my medical information to determine and obtain insurance benefits for product and services provided to me by the provider I agree to transfer immediately to the provider any payment made directly to me for product and/or services provided by the Facility. I authorize the provider to appeal denied insurance authorization and /or benefits Financial Responsibility: I understand any agree that: (1) I am financially responsible to the provider for the payment of applicable deductibles and coinsurance and any other amounts that are not covered to my insurance unless otherwise provided by laws, regulation or DME supplier contractual relationships: (2) the actual amount I will owe depends on my insurance plan, whether my deductible has been reached, and whether I have secondary coverage such as Medigap: (3) If I have supplemental insurance , that plan may cover my coinsurance obligation in whole or in part (4) if I am unable to pay the full amount. The provider will work with me to establish a payment plan that fits within my budget: and (5) the provider has a policy regarding hardship and will assess on a case by case if a patient qualifies financial assistance. To apply for financial assistance or to establish a payment plan, contact Pain Management Center for billing service (276-663-1423) Email & Phone Call Acknowledgment: By providing my email address & Phone #. I authorize the facility to contact me regarding care and services related to the product I have received and that it will not be used for any other purpose. Portions of the correspondence may not be encrypted therefore the facility cannot ensure or warrant the security of any information transmitted or received by email. For any question regarding my right, I will refer to the provider’s Notice of privacy practices.
*
I acknowledge that all information I provided int his form is true and accurate.
Signature
*
Date Signed
*
-
Month
-
Day
Year
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