PATIENT INFORMATION NAME: DOB: AGE: ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL: WORK: *Please list your email address for the patient portal. It will not be used for any commercial communication. RACE: (Please circle one) American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific, Black or African American, Caucasian, Hispanic, Other Race, Other Pacific Islander, Refuse to Report ETHNICITY: (Please circle one) Hispanic or Latin, Not Hispanic or Latin, Refuse to Report LANGUAGE: (Please circle one) English, Indian (includes Hindi and Tamil), Spanish, Russian, & other PHARMACY NAME: PHONE: FAX: PHARMACY ADDRESS: CITY: STATE: ZIP: PHYSICIAN INFORMATION PCP NAME: (FIRST) LAST: ADDRESS: CITY: STATE: ZIP: PHONE: REFERRED BY: (FIRST) LAST: REFERRERS S ADDRESS: CITY: STATE: ZIP: PHONE: Family Friend M.D Other
INSURANCE INFORMATION PRIMARY INSURANCE: ID #: SUBSCRIBER: DOB: RELATIONSHIP: SECONDARY INSURANCE: ID #: SUBSCRIBER: DOB: RELATIONSHIP: FUTURE APPOINTMENT REMINDERS: (Please check preference below) PHONE (#) TEXT (#) MUST CIRCLE YES OR NO *IS INJURY WORK RELATED? YES NO *IS INJURY MOTOR VEHICLE RELATED? YES NO *I GIVE MY PERMISSION FOR HAND SURGICAL ASSOCIATES, INC TO ACCESS MY MEDICATION LIST FROM AN EXTERNAL SOURCE YES NO I, the undersigned, verify that the information listed above is true and accurate to the best of my knowledge. Any changes to the information listed have made and initialed. RELEASE OF INFORMATION AUTHORIZATION: I, the undersigned, authorize the release of any information required in the course of treatment to my insurance carrier or other health provider I am consulting. ASSIGNMENT OF BENEFITS AUTHORIZATION: I, the undersigned, assign to the provider(s) or supplier all insurance payments for the medical services rendered. I also acknowledge responsibility for payment of all medical fees in the event they are not paid by my insurance plan. Signature Date If the patient is a minor please provide your name and relationship to the patient NAME: (Please print) RELATIONSHIP TO PATIENT:
Hand Surgical Associates Paul Feldon, MD 125 Parker Hill Ave Hervey Kimball, MD Boston, MA 02120 Edward Nalebuff, MD 617 738-0857 Andrew Terrono, MD Health Questionnaire Please answer all questions completely and/or check appropriate boxes Date: / / Name: Person completing form: Self Other Date of Birth: / / Name/Relation: Height: Weight: Are you right or left handed? Right Left Ambidextrous Current Occupation: Prior Occupations: Education completed: Technical school, High school, College, Graduate school Describe your main problem: Did you have an injury? Yes No If so how / when? Which side is affected? Right Left Both If both, which is worse? Right Left When did it start? What makes it better? What makes it worse? At night is it? Better Worse No change Describe pain (if present): Burning Sharp Radiating (to: ) Constant Intermittent Pain location: Neck Shoulder Arm Elbow Forearm Wrist Hand Have you ever had similar symptoms? Yes No If yes, when? Have you seen any other doctors for this problem? Yes No If yes, please list: (please bring all your medical records regarding this problem) Please mark the treatment or tests you have had for this problem X-rays Arthrogram CT scan MRI EMG/NCV (nerve test) Myelogram Hand therapy Occupational therapy Physical therapy Acupuncture Pain clinic treatment Nerve block Trigger point injection Cortisone injection Chiropractic treatment (please bring all the results and actual x-ray films or CD for this problem) Is your problem work related: Yes No Are you currently working? Yes No If No: When did you last work? / / Do you have an attorney for this current problem? Yes No (Please complete other side)
Health Questionnaire: Medical History (page 2) Do you have any allergies to medicines? Please list (if yes) : No Yes Are you allergic to penicillin? No Yes Allergic to latex? No Yes Are you taking any medication? No Yes (you may add extra sheets as needed) Please list (if yes) : Are you taking blood thinners? No Yes : name Have you had any operations? No Yes (you may add extra sheets as needed) Please list (if yes) : Do you smoke tobacco? No Yes If yes, how much and kind? # years Do you drink alcohol? No Yes If yes, how much and kind? # years Are you pregnant? Do you have any of the following problems? No Yes Possibly N/A Heart arrhythmia No Yes Gall bladder No Yes Lung disease No Yes Heart attack No Yes Bowel No Yes Asthma No Yes High blood pressure No Yes Kidney No Yes Emphysema No Yes Aortic or Mitral valve No Yes Bladder No Yes Tuberculosis No Yes Chest pain No Yes Diabetes No Yes Infectious disease No Yes Pacemaker No Yes Thyroid No Yes Hepatitis No Yes Circulation problem No Yes Arthritis No Yes Liver disease No Yes Stroke / TIA No Yes Gout No Yes Bleeding disorder No Yes Blood clot No Yes Rheumatic fever No Yes Healing No Yes Seizures Anesthesia problems No Yes No Yes Anxiety / Nervousness Depression Within the past year, have you had any of the following? No Yes No Yes Cancer Type: No Yes Fever / Chills No Yes Shortness of breath No Yes Chest pain No Yes Weight loss or gain > 10 lbs No Yes Nausea / Vomiting No Yes Numbness or tingling No Yes Visual changes No Yes Ear / Nose / Throat problem No Yes Fractures (broken bones) No Yes Headaches No Yes Skin problem No Yes Back pain No Yes Dizziness / Fainting No Yes Bleeding problem No Yes Anxiety / Depression No Yes Do you have a family history of any of the following problems? Heart disease No Yes Bowel disorder No Yes Vascular disease No Yes Heart attack No Yes Kidney disorder No Yes Stroke / TIA No Yes Aortic or mitral valve No Yes Bladder disorder No Yes Blood clot No Yes Rheumatic fever No Yes Diabetes No Yes Lung disease No Yes Pacemaker No Yes Thyroid disorder No Yes Bleeding disorder No Yes Arthritis Anesthesia problems No Yes No Yes Gout No Yes Cancer Type: No Yes
THE QuickDASH OUTCOME MEASURE INSTRUCTIONS This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer every question, based on your condition in the last week, by circling the appropriate number. If you did not have the opportunity to perform an activity in the past week, please make your best estimate of which response would be the most accurate. It doesn t matter which hand or arm you use to perform the activity; please answer based on your ability regardless of how you perform the task.
QuickDASH Please rate your ability to do the following activities in the last week by circling the number below the appropriate response. NO MILD MODERATE SEVERE DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY UNABLE 1. Open a tight or new jar. 2. Do heavy household chores (e.g., wash walls, floors). 3. Carry a shopping bag or briefcase. 4. Wash your back. 5. Use a knife to cut food. 6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.). NOT AT ALL SLIGHTLY MODERATELY QUITE A BIT EXTREMELY 7. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbours or groups? NOT LIMITED SLIGHTLY MODERATELY VERY AT ALL LIMITED LIMITED LIMITED UNABLE 8. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem? Please rate the severity of the following symptoms in the last week. (circle number) NONE MILD MODERATE SEVERE EXTREME 9. Arm, shoulder or hand pain. 10. Tingling (pins and needles) in your arm, shoulder or hand. SO MUCH NO MILD MODERATE SEVERE DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY THAT I CAN T SLEEP 11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number) QuickDASH DISABILITY/SYMPTOM SCORE = of completed responses. ( ) (sum of n responses) - 1 x 25, where n is equal to the number n A QuickDASH score may not be calculated if there is greater than 1 missing item.
QuickDASH WORK MODULE (OPTIONAL) The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (including homemaking if that is your main work role). Please indicate what your job/work is: _ I do not work. (You may skip this section.) Please circle the number that best describes your physical ability in the past week. Did you have any difficulty: NO MILD MODERATE SEVERE DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY UNABLE 1. using your usual technique for your work? 2. doing your usual work because of arm, shoulder or hand pain? 3. doing your work as well as you would like? 4. spending your usual amount of time doing your work? SPORTS/PERFORMING ARTS MODULE (OPTIONAL) The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument or sport or both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which is most important to you. Pleaseindicatethesportorinstrumentwhichismostimportanttoyou : _ I do not play a sport or an instrument. (You may skip this section.) Please circle the number that best describes your physical ability in the past week. Did you have any difficulty: NO MILD MODERATE SEVERE DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY UNABLE 1. using your usual technique for playing your instrument or sport? 2. playing your musical instrument or sport because of arm, shoulder or hand pain? 3. playing your musical instrument or sport as well as you would like? 4. spending your usual amount of time practising or playing your instrument or sport? SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by 4 (number of items); subtract 1; multiply by 25. An optional module score may not be calculated if there are any missing items. INSTITUTE FOR WORK & HEALTH 2006. ALL RIGHTS RESERVED
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. If you have any questions about this Notice, please contact our Privacy Officer at the number listed at the end of this Notice. Each time you visit a healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This Notice applies to all of the records of your care generated by your health care provider. Our Responsibilities Hand Surgical Associates, Inc. is required by law to maintain the privacy of your health information and to provide you with a description of our legal duties and privacy practices regarding your health information. The current Notice will be posted in the waiting room and on our website at www.bostonhand.com. The notice will include the effective date. In addition, we will make our best effort to provide you with a copy of this notice that we request you acknowledge with your signature. We are required by law to abide by the terms of this Notice and notify you if we make changes to this Notice, which may be at any time. Changes to the Notice will apply to your medical information that we already maintain as well as new information received after the change occurs. If we change our Notice, it will be posted in the waiting room and on our website at www.bostonhand.com. You may also request that a revised Notice be sent to you in the mail or you may ask for one at your next appointment or appropriate visit. This Notice will also serve to advise you as to your rights with regard to your medical information. How We May Use and Disclose Medical Information About You. The following categories describe examples of the way we use and disclose medical information: For Treatment: We may use medical information about you to provide, coordinate and manage your treatment or services. We may disclose medical information about you to other doctors, nurses, technicians, medical students, or other personnel who are involved in your care. We may also disclose medical information to clinical laboratories and imaging facilities during the course of your care and treatment. For example, a laboratory or medical specialist may need to know information about you to run tests or to provide treatment. We may also provide a subsequent healthcare provider with copies of various reports that should assist him or her in treating you. For example, your medical information may be provided to a physician to whom you have been referred so as to ensure that the physician has appropriate information regarding your previous treatment and diagnosis. For Payment: We may use and disclose medical information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information before it approves or pays for the health care services we recommend for you. The insurance company may use that information in connection with making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. For Health Care Operations: We may use or disclose, as needed, your health information in order to support our business activities. These activities may include, but are not limited quality assessment activities, employee review activities, training of medical students, licensing, marketing, legal advice, accounting support, medical records storage and conducting or arranging for other business activities. For example, we provide medical records to a storage company for long-term safekeeping. In addition, we may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment by telephone. Business Associates: There are some services provided in our organization through contracts with business associates. Examples include quality accounting, legal services, billing services, transcription services, billing/collection agencies, and record storage services. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job that we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information through a written contract. Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object We also may use and disclose your health information as set forth below. You have the opportunity to agree or object to the use or disclosure of all or part of your health information in these instances. If you are not present or able to agree or object to the use or disclosure of the health information (such as in an emergency situation), then your clinician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the information that is relevant to your health care will be disclosed. Individuals Involved in Your Care or Payment for Your Care: Unless you object, we may release medical information about you to a friend or family member who is involved in your medical care or who helps to pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. Future Communications: We may communicate to you via newsletters, mailings or other means regarding treatment options; information on health-related benefits or services, disease- management programs, wellness programs; to assess your satisfaction with our services; to remind you that you have an appointment for medical care; as part of fund raising efforts; for population based activities relating to improving health or reducing health care costs; for conducting training programs or reviewing competence of health care professionals; or other community based initiatives or activities in which our facility is participating. If you are not interested in receiving these materials, please contact our Privacy Officer. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Object We may use or disclose your health information in the following situations without your authorization or without providing you with an opportunity to object. These situations include: As required by law. We may use and disclose health information to the following types of entities, including but not limited to: Food and Drug Administration Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability Correctional Institutions Workers Compensation Agents Organ and Tissue Donation Organizations Military Command Authorities Health Oversight Agencies Funeral Directors, Coroners and Medical Directors National Security and Intelligence Agencies
Protective Services for the President and Others Authority that receives reports on abuse and neglect Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. State-Specific Requirements: Many states have requirements for reporting including population-based activities relating to improving health or reducing health care costs. Your Health Information Rights Although your health record is the physical property of the Hand Surgical Associates, Inc. that compiled it, you have the right to: Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. We ask that you submit these requests in writing. Usually, this includes medical and billing records, but does not include psychotherapy notes or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. Requests for access to and copies of your medical information must be submitted to HSA in writing. The cost for copies is per Board Regulations. Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information by submitting a request in writing. You have the right to request an amendment for as long as we keep the information. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial. An Accounting of Disclosures: You have the right to request an accounting of our disclosures of medical information about you except for certain circumstances, including disclosures for treatment, payment, health care operations or where you specifically authorized a disclosure. Hand Surgical Associates, Inc. will provide the first accounting to you in any 12-month period without charge. Hand Surgical Associates, Inc. will impose a fee of $10.00 each subsequent request for an accounting within the 12-month period. We ask that you submit these requests in writing. Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure that you had. We ask that you submit these requests in writing. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes. We ask that you submit these requests in writing. A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing. Complaints If you believe your privacy rights have been violated, you may file a complaint with us by calling (617) 738-0857 and asking for the Privacy Officer or by contacting the Secretary of the Federal Department of Health and Human Services. All complaints must also be submitted in writing. You will not be penalized for filing a complaint. Other Uses of Medical Information Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission and we are required to retain our records of the care that we provided to you. Privacy Officer: Nina Bonazzi Telephone Number: (617) 738-0857 Effective Date April 1, 2003 Hand Surgical Associates, Inc. 125 Parker Hill Avenue Boston, MA 02120 Health Insurance Portability and Accountability Act of 1996 Privacy Policies and Procedures
Acknowledgement Receipt of Notice of Privacy Practices By my signature below, I acknowledge receiving a copy of Hand Surgical Associates, Inc. s Notice of Patient Privacy Practices. Patient Name (Please Print) Date Patient Signature Date If the patient is a minor please provide your name and relationship to the patient: NAME: (Please print) RELATIONSHIP TO PATIENT: