21031 Michigan Avenue Fort Street Health Riverview) Dearborn, MI Trenton, MI 48183
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1 21031 Michigan Avenue Fort Street Health Riverview) Dearborn, MI Trenton, MI Phone: Fax: Date: Dear Patient: An appointment has been scheduled for you at Michigan Orthopedic Specialists with Dr. Eric Silberg at the office location above. New Patients, please arrive 15 minutes Appointment Date: prior to scheduled appointment time with your completed paperwork. Appointment Time: Enclosed are forms to be completed before your scheduled appointment. It is important that all pages are completed and accurate to help with the doctor s evaluation of your problem. Please include your signature, after carefully reading the enclosed policies. The following items need to be brought with you: Failure to report accurate insurance information will result in the delay or cancellation of your appointment. Picture I.D (driver license or state id) Insurance cards o If you have an HMO, you must bring a referral with you (most offices will no longer fax referrals). You will not be seen without a referral. Your copay & deductible (if applicable) Work related or Auto related injury requires a written letter of open claim including claim#, billing address and name of contact person (case manager) with their phone # Actual xrays on film or CD related to your appointment. We do require that you bring your most recent MRI/CT scan and report with you for your consultation. Reports alone are not acceptable. Please bring the actual films or disc with images. If you do not have a CD, please contact the imaging center to receive a hard copy. A list of medications and supplements that you take (complete enclosed form) Your primary care, referring doctor and cardiologists (if applicable) address, phone and fax # s so that we can coordinate care if appropriate Pharmacy address, phone and fax # as we e prescribe all eligible medications address, if not already provided to the staff member who made your appointment. This will enable you to access our Electronic Medical Record system If there is a language barrier, please be advised that you will need to bring a translator that is 18 years of age or older with you Please contact our office if you have any questions. Visit our website: for driving directions. We look forward to providing your care. Sincerely, The Office of Eric T. Silberg M.D. Last updated: 2014 tla
2 PATIENT INFORMATION Name: Date of Birth: Age: Address One: Social Security #: City: Sex: State: Zip: Height: Weight: Home Phone#: Work Phone#: Cell Phone#: Employer: Emergency Contact: Emergency Phone#: Marital Status: Single Married Widowed Divorced Emergency Relationship: INSURANCE INFORMATION Primary Insurance: Subscriber Name: Secondary Insurance: Subscriber Name: Subscriber Birthdate: Co-Pay $: Subscriber Birthdate: Co-Pay $: Subscriber SSN: Who referred you to this office? DR Attorney (self referral) Family Doctor: Subscriber SSN: Referral Address: Doctor s Address: MD Phone: MD Fax: Were you seen in an emergency room for this problem? yes no If patient is over 18, are you a full time student? yes no Hospital: Date: In this section, check the ONE BOX that best describes how your problem started, then answer the questions. Use as much space as needed in the comment section. Comments No Injury (onset was gradual or sudden Why do you think it started? Injury (accident or sport) Not auto or work Where & how did it happen? Injury at work Date: From a lift twist fall bend pull reach Auto accident Date: How was your vehicle hit? Page 1 of 4 ETS/JCF
3 PATIENT NAME: DOB: Medical History: (your health issues): check all that apply None thyroid disease kidney disease heart disease liver disease cancer: high blood pressure ulcers acid reflux angina/chest pain stroke bleeding/clotting problem heart attack seizures blindness/vision difficulty high cholesterol diabetes substance abuse asthma tuberculosis mental disorder COPD/emphysema anemia/prior blood transfusion Other: Surgical History: (list all surgeries and dates if known) Family History: heart disease diabetes cancer high blood pressure arthritis Social History: Smoker: no yes packs/day quit smoking (year) Alcohol: none occasional frequent (most days drinks) Do you currently experience any of the following? (check all that apply) If none apply, check here General: weight loss fevers fatigue Cardiovascular: chest pain irregular rhythm heart murmur Gastro intestinal: heartburn stomach ulcers hepatitis Musculoskeletal: arthritis osteoporosis prior fracture Neurological: dizziness weakness headaches Respiratory: sleep apnea shortness of breath Urinary: painful urination urinary infection Endocrine: diabetes thyroid problems Hematology: blood clots bleeding problems Immunologic: tuberculosis HIV/AIDS infection Psychiatric: depression anxiety Eyes: need glasses glaucoma Ears/Nose/Throat: hearing loss sinus infections Skin: rash / sores psoriasis Page 2 of 4 ETS/JCF
4 MEDICATION RECORD Dr. Eric T. Silberg Patient Name: DOB:_ Pharmacy: Phone: Fax: Address: Allergic To: ALLERGIES/REACTIONS Reaction: CURRENT MEDICATION PLEASE INCLUDE SUPPLEMENTS AND VITAMINS DATE MEDICATION DOSAGE QTY Patient Signature: Date Page 3 of 4 ETS/JCF 2014
5 PATIENT NAME: DOB: AUTHORIZATION FOR TREATMENT & PAYMENT The above information is true to the best of my knowledge. I hereby authorize treatment of the above named person and acknowledge to that I am able to read, write and understand English and if not, I have brought an adult with me who is able to interpret on my behalf. I authorize Michigan Orthopedic Specialists to furnish information to my current or future insurance carrier(s) any information needed for the purposes of securing payment for services provide and assign all payment for services provided to the physician listed above all. I understand that I am financially responsible for any amounts not covered by my insurance and any co-pay, co-insurance, balance or deductible will be collected before I am treated by the physician. Any amounts owing after my insurance has paid will be remitted promptly upon receipt of a statement. It is my responsibility to obtain any authorization required prior to seeing the specialist and I may not be seen without it if required due to insurance. PATIENT/GUARDIAN SIGNATURE: DATE: PATIENT CONTACT INFORMATION Many of our patients allow family members such as their spouse, parents or others to call and request medical or billing information. Under the requirements of HIPAA we are only allowed to release information without the patient s consent for specific uses related to treatment, payment and operations as outlined in our privacy notice. If you wish for us to release/discuss your medical or billing information with other individuals you must sign this form. You have the right to revoke this request in person or writing at any time. Home Telephone (# ) Okay to leave message with detailed information Leave message with call back number only Work Telephone (# ) Okay to leave message with detailed information Leave message with call back number only address:( ) It is okay for the doctor to communicate with me via It is okay for the staff to communicate with me via Text Message (#) Okay to text message me Other Restriction: I hereby give permission to Michigan Orthopedic Specialists to discuss my treatment or bill with the following individuals: (check all that apply): Spouse Name: Contact # Child Name: Contact # Parent Name: Contact # Other & Relationship: Contact # The above named individuals have my permission to pick up forms, samples, medical equipment or prescriptions on my behalf. I understand that ID may be requested by the staff before these items are released. Please be advised that in an emergency situation, or if we are unable to reach you for urgent medical matters through the numbers provided, we will contact the emergency contact listed on the Patient Information Form. PATIENT/GUARDIAN SIGNATURE: DATE: ACKOWLEDGEMENT OF PRIVACY PRACTICES By signing below I acknowledge that I have received a copy of this office s Notice of Privacy Practices Form when I presented to the office. PATIENT/GUARDIAN SIGNATURE: DATE: For office use only: On, 20, I presented this Acknowledgement of Receipt of Notice of Privacy form to the above named patient and/or their guardian. Parent/guardian returned; staff witness below. The Patient refused to provide signature when requested. Other (list): Office Staff Signature: DATE: Page 4 of 4 ETS/JCF
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