APPOINTMENT CONFIRMATION (New Patient)

Transcription

1 APPOINTMENT CONFIRMATION (New Patient) Date: Dear Mr./Ms. : This letter shall confirm your appointment with: Harlan C. Amstutz, M.D. Thomas P. Schmalzried, M.D. H. Michael Mynatt, M.D. Andrew J. Wassef, M.D. on at a.m./p.m. The Joint Replacement Institute is located on the fourth floor of The S. Mark Taper Building at 2200 W. Third Street., Suite 400. Please refer to the enclosed map. Please complete the enclosed forms and bring them with you to your appointment along with your health insurance cards and a photo identification card. As a courtesy to our patients, our office will bill the primary insurance company if outpatient coverage is verified. However, any applicable deductibles, and/or co-payments must be paid at the time of your appointment. We accept cash and checks. Dr. Schmalzried does accept credit/debit cards. ADDITIONAL INFORMATION: Costs X-rays Costs associated with your medical care will depend upon your specific diagnostic requirements and treatments. If Indicated, x-rays and other special studies (CT, MRI, Bone Density, etc.) may be performed during your visit. If you do not have insurance, you will be expected to pay for these services at the time of your visit. Please note that you and/or your insurance company will receive separate statements from: 1. St. Vincent Medical Center for a) the technical service component related to x-rays and other special studies, b) chargeable medical supplies, and c) facilities fee 2. The hospital s radiologist(s) for the professional service component related to the interpretation of x-rays and other special studies or procedures. 3. Your orthopaedic surgeon. Parking The S. Mark Taper Building has underground parking. Parking is $3.00 with validation. Metered street parking is also available. Please do not hesitate to contact our office at should you have any questions. Our office hours are Monday through Friday from 8:30 a.m. to 5:00 p.m. Sincerely, Coordinator (J:Forms//Appt Confirmation for JRI) 2200 W. Third St., Suite 400, Los Angeles, CA Ph: Fax:

2 JOINT REPLACEMENT INSTITUTE Map and Directions 2200 W. Third Street, Suite 400 Los Angeles, CA Joint Replacement Institute is located across from St. Vincent Medical Center which is located in the heart of Los Angeles at the corner of 3rd Street and Alvarado Street, just West of Downtown Los Angeles. From the South: Take the 110 Harbor Freeway North, exit at 3rd Street and proceed West approximately 2 miles to Alvarado Street. The medical center is on the corner of 3rd and Alvarado Street. Then make a left onto Lake Street. The S. Mark Taper Foundation Building is located to the right on the corner of Lake St. and Ocean View. From the North: Take the 101 Hollywood Freeway South, exit at Alvarado Street, proceed South on Alvarado 3/4 of a mile. The medical center is on the corner of 3 rd and Alvarado Street. Please make a right onto 3 rd and a left onto Lake Street. The S. Mark Taper Foundation Building is located to the right on the corner of Lake St. and Ocean View. From the West: Take the 10 Santa Monica Freeway to the 110 Harbor Freeway North, exit at 3rd Street and proceed West approximately 2 miles to Alvarado Street. Then make a left onto Lake Street. The S. Mark Taper Foundation Building is located to the right on the corner of Lake St. and Ocean View. From the East: Take the 10 San Bernardino Freeway to the 110 Harbor Freeway North, exit at 3rd Street and proceed West approximately 2 miles to Alvarado Street. Then make a left onto Lake Street. The S. Mark Taper Foundation Building is located to the right on the corner of Lake St. and Ocean View. Jojnt Replacement Institute 2200 West 3 rd Street, Suite 400 Los Angeles, CA (213) Joint Replacement Institute is Located in the S. Mark Taper Foundation Building

3 DATE: NAME: AGE: FEMALE MALE Please circle the physician you are scheduled with today: Harlan C. Amstutz, M.D. H. Michael Mynatt, M.D. Thomas P. Schmalzried, M.D. Jonathan R. Saluta, M.D. Marc A. Samson, M.D. Andrew J. Wassef, M.D. How did you hear about the Joint Replacement Institute? (Circle and fill in line, if applicable) a. My doctor Family Physician (name) Internist (name) Rheumatologist (name) Other (name) b. Friend or family Someone with arthritis or other orthopedic problem Someone who had joint surgery or other procedure Someone who did the research for me c. Internet/Web site List site if you can remember d. You are a patient at another St. Vincent Medical Center clinic (Spine Institute, Orthopaedic Institute, Cardiac Care Institute, etc.) e. Yellow pages in phone book f. Advertisement in magazine or newspaper: List name of publication if you can remember g. Article or news story h. Television Broadcast Cable i. Community Talk j. Other Thank You.

4 PATIENT ACCESS DEPARTMENT NEW PATIENT INTAKE FORM TODAY S DATE: PATIENT S INFORMATION: PATIENT NAME (LAST, FIRST): MALE / FEMALE SOCIAL SECURITY: BIRTHDATE BIRTH PLACE: ADDRESS: CITY: STATE: ZIPCODE: HOME PHONE #: CELL PHONE #: ALTERNATE #: DRIVERS LIC/ID #: PRIMARY LANGUAGE: ETHNICITY: RELIGION: MARITAL STATUS: ADDRESS: FAMILY PHYSICIAN: FAMILY PHYSICIAN PHONE #: RETIRED: YES NO DO YOU SMOKE (WITHIN THE PAST 12 MONTHS): YES NO PATIENT S EMPLOYER: (IF A MINOR, THEN PARENT/GUARDIAN S EMPLOYER) EMPLOYER NAME: WORK #: OCCUPATION: ADDRESS: CITY: STATE: ZIP CODE: EMERGENCY CONTACT: NAME: RELATIONSHIP: ADDRESS: CITY: STATE: ZIP CODE: PHONE #: CELL PHONE #: ALTERNATE #: INSURANCE/PAYOR INFORMATION: PRIMARY INSURANCE CARRIER: HMO / PPO/POS NAME INSURED: SUBSCRIBER ID: SECONDARY INSURANCE CARRIER: HMO / PPO/POS NAME INSURED: SUBSCRIBER ID: PLEASE COMPLETE IF IT IS WORKER S COMPENSATION: CLAIM # BODY PART(S): DATE OF INJURY: INDUSTRIAL CARRIER: CARRIER ADDRESS: ADJUSTER NAME: ADJUSTER PHONE #: ATTORNEY NAME: ATTORNEY PHONE #:

5 PATIENT MEDICAL HISTORY NAME: DATE: 1.The following is a list of common health problems. Please circle yes or no in the columns as appropriate. Did you receive treatment for it? Does it limit your activities? Do you have the Problem? Heart Disease Yes No Yes No Yes No High Blood Pressure Yes No Yes No Yes No Lung Disease Yes No Yes No Yes No Diabetes Yes No Yes No Yes No Ulcer or Stomach Disease Yes No Yes No Yes No Kidney Disease Yes No Yes No Yes No Liver Disease Yes No Yes No Yes No Anemia or other Blood Disease Yes No Yes No Yes No Cancer Yes No Yes No Yes No Depression/Emotional Problems Yes No Yes No Yes No Osteoarthritis, Degenerative Arthritis Yes No Yes No Yes No Back Pain Yes No Yes No Yes No Rheumatoid Arthritis Yes No Yes No Yes No Glaucoma Yes No Yes No Yes No Rheumatic Fever Yes No Yes No Yes No Sinusitis Yes No Yes No Yes No Urinary Tract Infection Yes No Yes No Yes No Other Medical Problems (please specify): Yes No Yes No Yes No 2. Menstrual: Yes No Brief explanation of any problems: Pregnancies: # Births: # 3. Have you been hospitalized for any reason, including previous surgeries? If yes, please explain: Type Hospital/Location Date A. B. C. D. E. F. 4. Were there complications? If yes, please indicate below: Yes Yes Other, Explain: Infection Thrombophlebits Bleeding Pulmonary Embolus 5. Allergies A. Are you allergic to: Yes No B. Foods, Please List: Penicillin Other Antibiotics Local Anesthetics C. Others, Please List: Iodine Aspirin Page 1 (OVER)

6 6. BLEEDING TENDENCIES A. Do you bruise easily? B: Do you bleed excessively if cut? C. Have you previously received a blood transfusion? If yes, please list any and all complications: D. Have you had any problems with healing after surgery, cuts or abrasions? If yes, please list: 7. Please note details of any serious injuries: 8. Have you taken any or are you currently taking any of the following medications: In Past Currently Taking Type Frequency Cortisone or Steroid Birth Control Pills Premarin Blood Pressure Pills Digoxin or Heart Pills Asprin, Bufferin, etc. Darvon Other Pain Medications Anticoagulants Eyedrops Inderol Other? Please list: FAMILY HISTORY 1. RECURRING MEDICAL PROBLEMS: MOTHER FATHER Health Status Health Status 2. ORTHOPAEDIC PROBLEMS IN FAMILY: Age at Death Age at Death 3. DIABETES MATERNAL GRANDMOTHER PATERNAL GRANDMOTHER 4. CANCER: Health Status Health Status Age at Death Age at Death 5.. INFECTIOUS DISEASE: MATERNAL GRANDFATHER PATERNAL GRANDFATHER Health Status Health Status 6. OTHER: Age at Death Age at Death Do Not Write Below This Line To Be Completed by Physician PRESENT ILLNESS: OTHER SERIOUS INJURIES/ILLNESSES: MEDICAL-LEGAL COMPENSATION ISSUES: Page 2

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8 JOINT REPLACEMENT INSTITUTE at St. Vincent Medical Center DISCLOSURE OF PHYSICIAN S FINANCIAL INTEREST IN CERTAIN MEDICAL DEVICES Dear Patient: As your physician, I may have a financial interest in certain medical devices that are used in your treatment and that I helped to invent or develop. Please note that I receive no compensation whatsoever for any medical devices that I may use in connection with your care. The only payments that I may receive are royalties or similar compensation for such medical devices used in the care of other patients for whom I do not provide patient care. Please let me know if you have questions regarding this matter. Your signature below acknowledges that you have read this disclosure. Sincerely, Thomas P. Schmalzried, MD Harlan C. Amstutz, MD Date: Patient s Signature Patient s Printed Name S:\FORMS\DISCLOSURE OF PHYSICIAN FINANCIAL INTEREST IN CERTAIN MEDICAL DEVICES.doc 2200 West Third Street, Suite 400 * Los Angeles, California * Tel: (213) * Fax: (213)

9 You Will Receive Separate Bills for Your Visit to Joint Replacement Institute The Physician s Bill The JRI Physicians are private doctors who provide direct treatment, diagnostic services, and/or supervision of care for patients they encounter in the Joint Replacement Institute. The Physician s Bill will only pertain to those professional services provided by your physician. The physician s bill can range from $465 for an initial evaluation to $105 for a follow up visit with the physician. This charge may vary depending on the complexity of your condition. If you have any questions pertaining to the JRI Physician s Bill, please contact the billing office at (818) Monday through Friday from 8:30 am to 5:00 pm. Physician bill payments and or insurance updates should be mailed to: California Orthopedics and Sports Medicine Associates, Inc Ventura Blvd. #203 Encino, California, The Hospital Bill The Hospital bill will only pertain to charges incurred for the use of the Joint Replacement Institute treatment area, any x- rays ordered, technical and ancillary personnel, supplies, and equipment. It will not include the JRI Physician s Fee. Charges from St. Vincent Medical Center for the clinic visit can range from $212 to $375 depending on the complexity of your condition. Charges for x-rays can range from $743 to $1486 depending on the x-ray views taken. These are only examples, and charges can vary for each visit. If you receive a joint injection, charges may vary from $926 to $1619, depending on the joint injected and the type of medication injected. For questions regarding St. Vincent Medical Center billing, please contact the Business Office at (213) You may receive bills for additional professional services, such as the reading of x-rays or lab tests. Neither St. Vincent Medical Center nor JRI Physicians have direct control of these charges. Please refer to the telephone number provided on those bills/statements for questions regarding charges. By your signature below, you are authorizing the assignment of benefits to the respective parties, and release of necessary medical information to obtain authorization for treatment and processing of your medical claims from you insurance company. You understand that you are financially responsible for the medical services that you receive regardless of whether your insurance company submits payment. You agree to pay, in a current manner, any charges not covered by your insurance company. Print Name Signature Date JRI: Forms/Clinic Forms-Professional Billing Updated 07/2012

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