Konigsberg Pediatric Orthopaedics

Todays Date

Date

Patient Name

Sex

Date of Birth

Date

Age

Height

Weight

Additional family members treated by Dr. Konigsberg? Name:

Name

Address

Street Address Line 2

CityState

Zip

Cell Phone

Work Phone

Please provide at least 2 different contact numbers. Indicate preferred phone number with a **

Email

example@example.com

Race optional

Referred By

Mothers Name

Fathers Name

Custody issues we should be aware of

Pediatricians Full Name

Pediatrician's Phone #

Address

Street Address Line 2

CityState

Zip

Reason for Todays Visit

How did it occur

Date Problem Began

Date

School Accident - Chronic Condition - Car Accident - Sports Accident - Noted at Birth

Any previous treatment

If ER visit which Hospital

Medical History: (check off all those that apply)

Family History

Patients Surgical History

Regular Medications

Is the patient allergic to any meds/foods/animals

Primary Insurance Information:

Primary Insurance

Subscriber ID

Subscriber Guarantor

Guarantor's Phone #

Relationship to Patient

Guarantors Birth Date

Date

City

State

Zip

Employer

Occupation

Secondary Insurance Information:

Secondary Insurance

Subscriber ID

Subscriber Guarantor

Guarantor's Phone #

Relationship to Patient

Guarantors Birth Date

Date

Address

Street Address Line 2

CityState

Zip

Employer

Occupation

Assignment and Release I authorize the above noted doctor and/or provider or supplier of services in this office to release any information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.I hereby authorize payment directly to Dr. Konigsberg all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance, for all services rendered on my behalf of my dependents. In the case that my account becomes delinquent, I understand that it will be forwarded to a Debt Collection Agency and that a fee of $50 will be added to my outstanding balance.

Signature of Responsible Party

Name of person completing form please print

Relationship to patient

Date

KONIGSBERG PEDIATRIC ORTHOPAEDICS

Phone # 201.445.9000 Fax # 201.445.7400

612 Godwin Avenue, Midland Park, NJ 07432

It is your responsibility to know whether our Practice participates with your particular health plan and program. Please provide this information to us in advance, and we will do our very best to comply with any reasonable requirements that your program may have. Some plans require a specific facility be used for your MRI, CT Scans, ultrasounds, or blood test Some programs require pre-authorization (We will get authorization for all surgical procedures, as well as MRI, CT Scans and Ultrasounds) Some insurance companies require that the PATIENTS notify them of any hospital admissions or trips to the ER.

Receiving Records You, the patient, are entitled to any and all records that pertain to your medical condition. For medical/legal reasons we never release the original records. Records are only released to the patient or someone that the person specifically designates to receive them. Copies of the office assessments, outside test results, and x-rays are available. Please note that there is a fee for copying records and X-

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA

The patient understands that: Protected health information may be disclosed or used for treatment, payment or health care operations. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The Practice reserves the right to change this Notice. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition treatment upon the execution of this Consent.

In order to protect your privacy, and in accordance with Federal Law, we do not leave confidential medical information on answering machines or with anyone other than the patient or patient's legal guardian without prior authorization. Please indicate your preference

We may leave detailed messages on your voicemail Do NOT leave detailed messages on any voicemail Permission to FAX medical instructions to my child's school

Patient Name

Signature of parent or legal guardian

Date

Relationship to patient

KPO

KONIGSBERG PEDIATRIC ORTHOPAEDICS

KPO