New Patient Intake Form (WC/PPO)

DEE SPORTS ORTHOPEDICS
PATIENT REGISTRATION FORM
Date

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Sex*
Marital Status*
Social Security
Address*

Home Address

Street Address Line 2

CityState

Zip Code
Home Phone*
Please enter a valid phone number.
Can we leave a voicemail?*
Mobile/ Other*
Please enter a valid phone number.
Can we leave a voicemail?*
Email
example@example.com
Occupation
Employer
Employer Phone No.
Primary Insurance Information
Insured Name
Relationship
Date of Birth

MonthDayYear
Date
Address (if different from patient)

Address If different from patient

Street Address Line 2

CityState

Zip Code
Insurance Company
Insurance Phone Number
Subscriber ID Number
Group No.
Please upload photo of your Insurance ID (Front)

Cancelof
Please upload photo of your Insurance ID (Back)

Cancelof
Preferred Pharmacy
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Emergency Contact
Name*
Relationship to Patient*
Home Phone
Mobile Phone*
The above information is true to the best of my knowledge. I authorize Dee Sports Orthopedics to release any info required to process my claims.
Patient/ Guardian Signature*

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Date*

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Date

NOTICE OF PRIVACY PRACTICES
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
- Conduct normal healthcare operations such as quality assessments and physician certifications
This notice is to inform you of the uses and disclosures of confidential information that may be made by DEE Sports Orthopedics and of your individual rights and DEE Sports Orthopedics legal duties with respect to confidential information.

I have been informed by you of your Notice of Privacy Practices, which contain a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices from time to time and that I may contact this office at any time.

DEE Sports Orthopedics reserves the right to change the terms of this Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, this practice. If changes to the policy occur, DEE Sports orthopedics will provide a revised Notice of Privacy Practices upon request.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I do hereby consent and acknowledge my agreement to the terms set forth in the NOTICE OF PRIVACY PRACTICES and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.
Patient signature or Responsible Person*

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Date*

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Date
Print Name*

ASSIGNMENT OF BENEFITS, RIGHTS, & CLAIMS
I hereby assign and convey directly to Derek Dee, MD as my designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by Derek Dee, MD, regardless of its managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize Derek Dee, MD to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to Derek Dee, MD any and all Plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from Derek Dee, MD or its attorney in order to claim such medical benefits.

In addition to the assignment of the medical benefits and/or insurance reimbursement above, I also assign and/or convey to Derek Dee, MD any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tort feasor insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from Derek Dee, MD (including any right to pursue those legal or administrative claims or chose an action This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims.

I intend by this assignment and designation of authorized representative to convey to Derek Dee, MD all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or mediations provided by Derek Dee, MD, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims The assignee and/or designated representative (Derek Dee, MD) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or laws; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chose in action or right against any liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. Derek Dee, MD, as my assignee and my designated authorized representative, may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider's expense.

Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original.

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.
Patient signature or Responsible Person*

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Date*

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Date
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REIMBURSEMENT POLICY
I understand that I am considered by the office of Dr. Derek Dee, M.D., to be insured.

Insurance Payment Information: I understand and agree that health insurance policies are in agreement between the insurance carrier and I (patient Furthermore, | understand that this orthopedic office will prepare any necessary billing, reports, and forms to assist me in making collections from the insurance company.

Should any reimbursement check(s) be issued from the insurance company and is paid directly to me, I agree to forward all check(s) to

Derek T. Dee, MD

7146 Edinger Ave Huntington Beach, CA 92647

Upon receipt of payment.

However, I clearly understand and agree that all services rendered to me are charged directly to the insured and I am personally responsible for payment. | also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable.

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.
Patient signature or Responsible Person*

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Date*

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Date
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FINANCIAL POLICY
Patients who carry health care insurance should understand that charges for professional services are billed to your insurance company as a courtesy only.

It is the responsibility of the patient/guardian to know and understand policies and benefits of their insurance. This includes:
- Co-payments
- Non-covered services
- Co-insurances
- Deductibles
- In and Out of Network benefits
- Office visits, second opinion, and surgery benefits
You are responsible for co-payments, deductibles and all non-covered charges. For an explanation of these charges, please contact your insurance company.

Please present any changes regarding medical insurance information, address, or telephone.

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.
Patient signature or Responsible Person*

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Date*

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Date
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INJECTION CONSENT FORM
The purpose of this document is to provide written information regarding the risks, benefits and alternativesof joint and soft tissue injections. This is supplementary to the discussion you will have with the doctor. It is important you fully understand this information so please read this document carefully.

The Procedure:

After the skin surface is thoroughly cleaned, the joint or soft tissue is entered with a needle attached to a syringe. At this point, either joint fluid can be obtained and sent for appropriate laboratory testing or medications/Platelet Rich Plasma/Stem Cell Therapy can be injected into the joint space. Commonly injected joints or soft tissue include the knee, shoulder, ankle, elbow and small joints of the hand and feet.

Benefits:

You might receive the benefit of relief from pain and swelling with this procedure but this cannot be guaranteed. Only you can decide if the benefits are worth the risk.

Risks:

Before undergoing one of these procedures, understanding the associated risks is essential. No procedure is risk- free. The following risks are well recognized, but there may also be risks not included in this list that are unforeseen by the doctors.
- There may be allergic reactions to the medicines injected into joints, to tape or the chemicals used to clean the skin for instance.
- There may be infection, although this is extremely rare. You may develop 'post-injection flare' which is joint swelling and pain several hours after any injections
- Local fat atrophy (thinning of the skin) at the injection site.
- Rupture of a tendon located in the path of the injection if inadvertently injected.
- Pain may be associated with this procedure and the healing process.
Alternatives:
- Oral anti-inflammatory drugs such as ibuprofen or naproxen.
- Physical therapy
I consent to being informed of any future procedure(s), risk, benefits and alternatives detailed above.
Patient signature or Responsible Person*

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Date*

MonthDayYear
Date
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X-RAY & FLUOROSCOPY CONSENT
TO THE PATIENT: You have the right to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involve. This disclosure is not meant to scare or alarm you. It is so that you may choose to give or withhold your consent to the procedure.

If you are pregnant or think that you may be pregnant, please inform the office immediately.

Derek Dee, M.D may request to perform an x-ray to obtain additional information. X-rays produce images of the internal body parts being examined. X-rays are painless, however, radiation is emitted. Therefore, it is critical for you to inform Derek Dee's office if there is any possibility you could be pregnant. Because the x-ray is a diagnostic procedure, it provides information that may aid Dr. Derek Dee in diagnosing and treating your medical condition. Without the x-ray, accurate diagnosis and proper treatment may be delayed.

During some fluoroscopic procedures, a contrast agent may be injected into your vein in order to produce better images of the part of your body that is being examined.

POTENTIAL RISKS - The following complications are possible anytime an injection is given, there is potential for pain, bleeding, bruising or swelling at the injection site. Exams requiring contrast may result in a mild headache, nausea, itching or other vague symptoms for a short time after the injection. Additional allergic reactions in response to the contrast agent may include hives, shortness of breath or difficulty swallowing. It is very important to inform Dr. Derek Dee's office, if you experience any of the conditions mentioned in this form

NOTE TO PATIENTS: If you previously had a reaction to a contrast injection such as hives, severe itching, shortness of breath and/or any significant reaction requiring hospitalization, a history of asthma, or other allergic conditions any history of anemia, sickle cell anemia, or kidney disorder, are pregnant or breast feeding you MUST inform Dr. Derek Dee's office.

There may be other imaging alternatives; however, Derek Dee, M.D. believes the x-ray to be the best diagnostic test for you, considering your symptoms and conditions to assist with a diagnosis.

I HAVE READ AND FULLY UNDERSTAND THIS CONSENT.
Patient signature or Responsible Person*

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Date*

MonthDayYear
Date
Print Name*

GENERAL MEDICAL HISTORY

Basic Information
Weight (in lbs.)*
Height (in feet and inches)*
Surgical History: (Type of Surgery, Date, Physician Name). Please put N/A if none.*
Prior Injuries (including motor vehicle accidents, worker's compensation, slip/fall, sports-related). Kindly indicate body part involved, description and date. Please put N/A if none.*
Prior treatment/ PRP injections (including physical therapy, chiropractor, massage therapy, epidurals. Kindly indicate body part involved, description and date. Please put N/A if none.*
Current Medications: Name of medications (be specific), Dose/Strength, and schedule taken. Please put N/A if none.*
Allergies to Medications or Materials. Specify the Allergen, Reaction. Please put N/A if none.*
Social Background
Do you smoke?*
If yes, how many packs per day?
For how many years?
Do you drink alcohol?*

NoYesOccasionallyDaily
Do you live with someone who can take care of you at home?
If yes, who?
I hereby certtify that the information provided above is trye and accurate.
Patient signature or Responsible person*

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Date*

MonthDayYear
Date

DEE SPORTS ORTHOPEDICS

PATIENT REGISTRATION FORM

Primary Insurance Information

Preferred Pharmacy

Emergency Contact

NOTICE OF PRIVACY PRACTICES

ASSIGNMENT OF BENEFITS, RIGHTS, & CLAIMS

REIMBURSEMENT POLICY

FINANCIAL POLICY

INJECTION CONSENT FORM

X-RAY & FLUOROSCOPY CONSENT

PAIN LOCATION SCALE

GENERAL MEDICAL HISTORY

Social Background

Please check all of the boxes that "yes" apply to: