Integrated Medical Services (IMS) PATIENT HISTORY Please PRINT and fill out completely

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1 Integrated Medical Services (IMS) PATIENT HISTORY Please PRINT and fill out completely Name: DOB/Age: Today s Date: / / How did you get referred to this office: Referral Source: Name: Primary Care MD: Name: Address: Address: Preferred Pharmacy Information Pharmacy Name: Phone #: Fax #: Address: City/State/Zip: REASON FOR TODAY S VISIT: INJURY HISTORY: Did the problem result from a specific injury? Yes No Was the injury due to a: Work Injury Injury/Accident Date: Car Accident Is / was there a lawyer involved in your injury? Yes How did you get injured? No How long have you had the condition? Please rate your pain on a scale of 0 to 10 (10 being the most painful): Is the pain: Constant Occasional Sharp Dull Aching Stabbing Throbbing Burning Electrical Shooting Spasmodic What symptoms are you experiencing? Numbness Swelling Locking Catching Giving Way Popping Grinding Stiffness Weakness Instability Night pain Pain with lifting Tingling Pain with overhead activity Other What, if anything, makes your symptoms better? What, if anything, makes your symptoms worse? Are you: Improving Getting Worse Staying the same Have you seen another physician for this problem/injury? Yes No If yes, who? What treatments have you tried? Nothing Physical Therapy Exercise Acupuncture Chiropractic manipulation Other Injections (specify: Cortisone, Supartz, Synvisc, Hyalgan) Pain medications: IMAGING STUDIES Test Date (month/year) Where were the tests done? X-rays MRI scan CT scan EMG/NCV 1

2 Other Patient Name: DOB: Page 2 MEDICAL HISTORY Please check current or previous medical conditions: Anemia Irregular Heartbeat Arthritis HIV Asthma Heart Attack Rheumatoid Arthritis Chemical Dependency Blood Clots High Blood Pressure Thyroid Alcoholism Cancer High Cholesterol Liver Disease Depression Diabetes Heart Disease Stroke/Seizures Hepatitis B or C COPD Poor Circulation Pulmonary Embolus Osteoporosis Other Have you ever had a blood transfusion? Yes No If yes, when? MEDICATIONS Please list all medications you are currently taking. Include antibiotics, blood thinners, insulin, heart medications, aspirin, and any other over-the-counter medications. Include vitamin, mineral, and herb supplements. Medication Dosage Frequency PAST SURGICAL HISTORY Please check any previous surgical procedures. List the date and location. Appendectomy Arthroscopy Lower Extremity Arthroscopy Upper Extremity Hernia Repair Spine/Back Surgery Heart Surgery Fracture Repair Total Joint Replacement o T&A o BSO o Other Hospitalizations (When): ALLERGIES Are you allergic to: Penicillin: Yes No Sulfa: Yes No Latex: Yes No No known drug allergies Please all other allergies: SOCIAL HISTORY Hand Dominance: Left Right Marital Status: S M W D What type of work do you do (job title): Tobacco Use: Yes No Type: Duration: Quit Date: Alcohol Use: Yes No Frequency: Street Drug Use: Yes No Frequency: GASTROINTESTINAL HISTORY Do you have a history of Peptic Ulcer Disease? Yes No If yes, when? Do you have a history of GI, stomach bleed? Yes No If yes, when? Do you take any medications for your stomach? (Please include over the counter medications: i.e. Pepcid, Tums, Zantac, etc. ) Include dosage and frequency. Have you ever taken anti-inflammatory medicine for a period greater than 30 days? (Please include over the counter medications such as Advil, Aleve, and previously prescribed medications, such as Celebrex and Vioxx. List all you have tried.) 2

3 Patient Name: DOB: Page 3 FAMILY HISTORY Please check family history conditions: Blood Clots Diabetes Hypertension Rheumatoid Arthritis Cancer Heart Disease Osteoporosis Stroke Seizures Other: REVIEW OF SYSTEMS Check if you have current symptoms or current known medical problems in the following areas. Please describe. If you do not have any problems, please check the Normal box. SKELETAL Arthralgias Joint Swelling Limb pain Joint Pain Joint Stiffness Limb Swelling CONSTITUTIONAL Normal Fever Feeling Poorly Recent Weight Gain( lbs) Chills Feeling tired (Fatigue) Recent Weight loss ( lbs) EYES Normal Eye Pain Eyesight Problems Dry Eyes Red Eyes Discharge From Eyes Eyes Itch EARS, NOSE Normal Earache Nose Bleeds Sore Throat Loss of Hearing Nasal Discharge Horseness HEART Normal Chest Pain Heart Rate is Fast Leg Claudication Palpitations Heart rate is slow Lower extremity swelling RESPIRATORY Normal Shortness of Breath Cough Difficulty breathing when lying down Wheezing Difficulty Breathing when exercising PND GI Normal Abdominal Pain Constipation Heartburn Vomiting Diarrhea Blood in Stool GU Normal Pain while Urinating Pelvic Pain Vaginal / Penile Discharge Incontinence Irregular Periods Abn Vaginal Bleeding SKIN Normal Itching Rash Breast Pain Skin Wound Change in a Mole Breast Lump NEUROLOGICAL Normal Confused Dizziness Limb Weakness Convulsions Fainting Difficulty walking PSYCHIATRIC Normal Suidical Anxiety Change in Personality Sleep Disturbance Depression Emotional Problems ENDOCRINE Normal Proptosis Muscle Weakness Feeling of Weakness Hot Flashes Deepening of Voice HEMATOLOGY Normal Easy Bleeding Swollen Glands Easy Bruising Other: WOMEN ONLY: Are you, or could you be pregnant? No YES Please inform the Medical Assistant and Radiology Tech. Signature: Date: Print Name: Physician Signature: Date: 3

4 Integrated Medical Services (IMS) New Patient Registration Sheet Personal Information Today s Date: Patient First Name: Initial: Last Name: DOB: Age: Social Security #: Address: Street Apt # City/State/Zip Home Phone: Work Phone: Cell phone: Gender : M F Language: ENG SPAN OTHER: Marital Status: S M W D O Ethnicity: Hispanic or Latino Non-Hispanic or Latino Declined Unknown Race: White Asian American Indian/Alaskan Native Black/African American Declined Unknown Native Hawaiian/Other Pacific Islander Financial Responsible Party Information Responsible Party Name: Relationship to patient: DOB: Age: Social Security #: Emergency Contact Name: DOB Phone Number: Relationship to patient: Insurance Information Primary Insurance: Address: Policy #: Group #: Policy Holder Name: DOB: Relationship to patient: Secondary Insurance: Address: Policy #: Group #: Policy Holder Name: DOB: Relationship to patient: I hereby authorize IMS to release any information required in the course of my examination or treatment to my insurance(s). I also hereby authorize payment directly to IMS for the surgical and/or medical benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges not covered by my insurance. Further, I understand that I am responsible for all charges incurred in the collection of my account(s) and will pay all fees involved should my account(s) be placed with a collection service. Finance charges will begin to accrue on any unpaid patient responsibility balance after 90 days old Patient/Guardian Signature Printed Name Date 4

5 Integrated Medical Services (IMS) Statement of Patient Financial Responsibility Patient Name: DOB: IMS ORTHOPEDICS, a division of IMS, appreciates the confidence you have shown in choosing us to provide for your health care needs. The service you have elected to participate in implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill. You are responsible for payment of any deductible and co-payment/co-insurance as determined by your contract with your insurance carrier. We expect these payments at time of service. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amounts not covered by you insurer. If your insurance denies any part of your claim, or if you or your physician elects to continue past your approved period, you will be responsible for your balance in full. Finance charges will begin to accrue on any unpaid patient responsibility balance after 90 days old. The above statements do not apply to those patients who are considered Worker s Compensation. However, please be advised that as an Industrial Patient, that you may be held responsible for your charges in the event your claim is denied. If you fail to make any payments for which you are deemed responsible for in a timely manner, after such default and upon referral to a collection agency or attorney by IMS, you will be responsible for all costs of collecting moneys owed, including but not limited to court costs, collection agency and/or attorney fees. I have read the above policy regarding my financial responsibility to IMS ORTHOPEDICS, for providing rehabilitative services to me or the above named patient. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to, IMS ORTHOPEDICS, a division of IMS, the full and entire amount of my bill incurred by me or the above named patient; or, if applicable any amount due after payment has been made by my insurance carrier. Co-Pay Policy Some health insurance carriers require the patient to pay a co-pay for services rendered. It is expected and appreciated at the time the service is rendered for the patients to pay at EACH VISIT. Thank you for your cooperation in this matter. Consent for Treatment and Authorization to Release Information I hereby authorize IMS ORTHOPEDICS, a division of IMS, through its appropriate personnel, to perform or have performed upon me, or the above named patient, appropriate assessment and treatment procedures. I further authorize IMS ORTHOPEDICS, and its affiliates, to release to appropriate agencies, any information acquired in the course of my or the above named patient s examination and treatment. Patient/Guarantor Signature: Date: Self-Pay (If applicable) I do not have health insurance and will be responsible for services rendered here at. I agree to pay IMS ORTHOPEDICS, a division of IMS, the full and entire amount of treatment given to me or to the above named patient at each visit. Patient/Guarantor Signature: Date: Motor Vehicle Insurance (PIP) _(If applicable) I do not have health insurance. I request my claims be submitted to my motor vehicle carrier. I understand I will be responsible for bills incurred by me in the even my PIP benefits exhausts or denies. Patient/Guarantor Signature: Date: 5

6 A DIVISION OF IMS Expert orthopedic care in your neighborhood Douglas B. Mangan, M.D., Amon T. Ferry, M.D., Michael Weng, M.D. Issada Thongtrangan, M.D., Christina Khoury, M.D., P. Stephen Mahoney, M.D N 3rd St., #2030 Phoenix, AZ W McDowell Rd., #203 Goodyear, AZ E. Bell Road Suite 3200 Paradise Valley. AZ M Daisy Mountain Dr., Suite 109 Anthem, AZ PHONE: (623) FAX: (623) Patient Name: DOB: OFFICE POLICY No patients under the age of 18 will be seen in our office without a written note from legal guardian. In the event a patient is unable to keep their scheduled medical appointment with their provider, a phone call must be received by our office 24 hours prior to appointment; otherwise an automatic $25.00 administrative fee may be charged to the patient account. We do not bill for co-pays. PAYMENT IS EXPECTED AT DAY OF SERVICE. There is a $25.00 fee for any paperwork that is to be completed by your orthopedic physician; this includes but is not limited to FMLA paperwork, Disability paperwork, and physical capacity statements. Payment is required prior to completion. Should a patient leave a message with our office, they can anticipate a return call by the next business day. No pain medications or routine medications will be called in AFTER HOURS. Patients will have to wait until the next working day to discuss with their provider. NO EXCEPTIONS. All patients are responsible for making their follow-up appointments and must arrive on time. Any patient that arrives 15 minutes after their scheduled appointment time may be asked to reschedule at the discretion of the provider. As a courtesy to our patients; our office makes every attempt to verify benefits and coverage for services provided and/or recommended. However, it is the patient s responsibility to know, understand, and be responsible for their insurance coverage. Inappropriate language and/or behavior while on the premises or by phone to any of IMS Orthopedics staff will not be tolerated at any time and WILL RESULT IN DISCHARGE FROM THE PRACTICE IMMEDIATELY. Should a patient cancel and/or no show three visits within a 12 month period, IMS Orthopedics reserves the right to discontinue the provider-patient relationship. A letter will be sent to the patient to notify of such. Should the patient need a copy of their medical records for personal use or continuity of care; please contact the medical records department. (Release of information form will be required). I have read the IMS Orthopedics, office policy. I will have a copy only if I asked for one. I agree to follow this policy at all times. Patient or Guardian Signature Date / / 6

7 Integrated Medical Services (IMS) HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Patient Name: DOB: This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out Treatment, Payment or Health Care Operations and for other purposes that are permitted by law. It also describes your rights to access and control your PHI. PHI is information about you, including demographic information, that may identify you and that relates to your past, present and future physical or mental health or condition and related health care services. Uses and Disclosures of PHI: Your PHI may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician s practice, and any other use required by law. At no time will any information of any kind relating to any of our patients be discussed outside of this office unless permitted or required by law. Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your PHI, as necessary, to a home health agency that provides care to you or to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose and treat you. Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for hospital admission. Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of your physician s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your PHI to medical school students that see patients at our office. In addition, we may use a signin sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may also use or disclose your PHI as necessary to contact you to remind you of your appointment. We are also permitted to use or disclose your PHI without your written authorization for certain purposes: As Required By Law, Public Health Activities (e.g. preventing the spread of disease), Health Oversight Activities, Abuse or Neglect, Food and Drug Administration Requirements, Legal Proceedings, Law Enforcement Purposes, Coroners, Funeral Directors and Organ Donation, Criminal Activity, Military Activity and National Security, Worker s Compensation, Inmates. Under certain circumstances, we may also use and disclose information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information and balances the research needs with patients need for privacy of their PHI. Before we use or disclose PHI for research, the project will have been approved through this research approval process. However, we may disclose your PHI to people preparing to conduct a research project, so long as the PHI they review is not removed from us. We may also use or disclose your PHI to contact you (or, under certain circumstances, to allow a research entity with whom we contract to contact you) about the possibility of enrolling in a research study. If you do not want to be contacted about the possibility of enrolling in a research study (as described above), please initial here: Other permitted and required uses and disclosures will be made with your authorization. You may revoke your authorization at any time in writing, except to the extent that your physician or the physician s practice has taken an action in reliance on the use or disclosure indicated in the authorization. We may not receive direct or indirect remuneration in exchange for your PHI without your authorization except in limited circumstances permitted by law. We may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments or health-related benefits and services. We do not receive any compensation in connection with communications with you about any products or services, except we may communicate with you about prescription drugs or biologics and receive payment from the manufacturer that is reasonable in amount and compensates us for the costs we incurred in connection with that communication. Except for communications about drugs or biologics, we will obtain your authorization if we will receive direct or indirect payment for communicating with you. We may enter into contract with entities known as Business Associates that provide services to or perform functions on our behalf. We may disclose PHI to Business Associates once they have agreed in writing to safeguard the PHI. For example, we may disclose your PHI to a Business Associate to administer claims. Business Associates are also required by law to protect PHI. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section Your Individual Rights: Following is a statement of your rights with respect to your PHI: You have the right to inspect and copy your PHI. If we use or maintain an electronic health record for you, you may get that information in electronic format and ask us to send it to a person or organization that you identify. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of or use in a civil, criminal or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. You have the right to request a restriction on the use or disclosure of your PHI. This means you may ask us not to use or disclose any part of your PHI for the purpose of Treatment, Payment or Health Care Operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. We will consider your request, but in most cases are not legally obligated to

8 agree to those restrictions (e.g., if your physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted, but you then have the right to use another Healthcare Provider). However, we will comply with any restriction request if the disclosure is to a health plan for purposes of payment or health care operations (not for treatment) and the PHI pertains solely to a health care item or service that has been paid for out-ofpocket and in full. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to have your physician amend your PHI. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. Your request for an accounting must be submitted in writing. If we use or maintain an electronic health record for you, you may get a list of the disclosures we have made, if any, of your electronic health record for three years prior to the date of your request. For accountings that do not include disclosures made through an electronic health record, the request may not cover a time period longer than six years from the date of the request. You have the right to be notified of a breach. You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of your unsecured PHI. Notice of any such breach will be made in accordance with federal requirements. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. This notice was published and becomes effective on/or before March 1, We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided by this notice. You can also request a copy of this notice at any time. You may complain to us or to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our HIPPA Compliance Officer. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of PHI and to provide individuals with this notice of our legal duties and privacy practices with respect to PHI. If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer in person or by phone at (888) Signature below is acknowledgment that you have read and understand our Privacy Practices. Patient Name: Signature: DOB: Date:

9 IMS Orthopedics Expert orthopedic care in your neighborhood Douglas B. Mangan, M.D., Amon T. Ferry, M.D., Michael Weng, M.D. Issada Thongtrangan, M.D., Christina Khoury, M.D., P. Stephen Mahoney, M.D N 3rd St., #2030 Phoenix, AZ W McDowell Rd., #203 Goodyear, AZ E. Bell Road Suite 3200 Paradise Valley. AZ M Daisy Mountain Dr., Suite 109 Anthem, AZ PHONE: (623) FAX: (623) AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION I authorize to disclose the following information from the health record of: PATIENT INFORMATION /_ /_ Patient Name Date of Birth Address ( ) Phone Number City State Zip Code Dates of Service: From To_ INFORMATION REQUESTED [ ] All Pertinent Records [ ] Operative Report [ ] Assessment(s) [ ] Pathology Report [ ] Consultation [ ] X-Ray Films [ ] Discharge Summary [ ] X-Ray Reports [ ] ER Report [ ] Billing Record [ ] History & Physical [ ] Specify: PURPOSE [ ] Self [ ] Continuing Medical Care [ ] Attorney Request [ ] Other (specify reason) INFORMATION TO BE GIVEN TO: ( ) ( ) Company, Person, Facility Phone Number Fax Number Address City State Zip Code I understand that information in my health record may include information relating to Sexually Transmitted Disease, Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV) and other communicable diseases, Behavioral Health Care/Psychiatric Care, and treatment of alcohol and/or drug abuse; my signature authorizes release of any such information. This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 CFR Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or is otherwise permitted by 42 CFR Part 2. The general authorization for the release of medical and other information is not sufficient for this purpose. The federal rules restrict the use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. I may refuse to sign this authorization form. I understand that IMS Orthopedics will not condition or deny treatment on my signing this authorization. I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. IMS Orthopedics Notice of Privacy Practices explains the process for revocation, which includes a request in writing. Unless I revoke this authorization earlier, it will expire 6 months from the date signed or as specified:. I understand that, if this information is disclosed to a third party, the information may no longer be protected by state, federal regulations and may be redisclosed by the person or organization that receives the information. I release IMS Orthopedics, its employees and agents, medical staff members, and business associates from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein. Signature of Patient Date In requesting the medical records as the designated agent, in signing below, I attest to the continuing inability of the above patient to make or communicate health care decisions. Signature of Legal Represents Relation to Patient or Description of Authority to Date Act for Patient