Boca Raton Location
1601 Clint Moore Rd., Suite 125
Boca Raton, FL 33487
Boynton Beach Location
2828 S. Seacrest Blvd. Suite 104/204
Boynton Beach, FL, 33435
PATIENT NAME: (LAST, FIRST, MIDDLE INITIAL)
LOCAL ADDRESS: (STREET, SUITE/UNIT, CITY, STATE, ZIP)
MARITAL STATUS: MARRIEDSINGLEDIVORCEDWIDOWEDOTHER
SOCIAL SECURITY #:
DATE OF BIRTH:
NEW PTESTABLISHED PT
HOW DID YOU HEAR ABOUT US? NEWSPAPERMAGAZINEINTERNETLECTUREBROCHUREFRIENDYELLOW PGS OTHER:
IS INSURANCE THROUGH EMPLOYMENT? YESNO
INSURANCE THROUGH SPOUSE OR PARENT? YESNO
SPOUSE / PARENT NAME:
DATE OF BIRTH:
PLEASE COMPLETE IF PATIENT IS CHILD OR STUDENT:
SOCIAL SECURITY #:
ADDRESS (If different from patient)
SOCIAL SECURITY #:
AUTHORIZATION FOR TREATMENT:
I hereby give my permission for Orthopaedic Surgery Associates, Inc. to evaluate and treat as deemed medically necessary.
I authorize Orthopaedic Surgery Associates to retrieve medication history information from Surescripts.
Uses insulin YESNO
Thyroid disorder YESNO
Coagulation disorder YESNO
History of DVT YESNO
History of pulmonary embolism (PE) YESNO
On blood thinning medication (Coumadin, Plavix, Pradaxa) YESNO
History of MRSA infection YESNO
Migraines / Headaches YESNO
Seizure disorder YESNO
TIA (mini-stroke) YESNO
Parkinson's disease YESNO
Loss of memory YESNO
Syncope (fainting) YESNO
Numbness / tingling in extremities YESNO
Macular degeneration YESNO
Use glasses / contacts YESNO
Change in vision YESNO
Tinnitus (ringing in ears) YESNO
Change in hearing YESNO
Use hearing aids YESNO
NOSE & MOUTH
NOSE & MOUTH
Sinus problems YESNO
Bleeding gums YESNO
Epistaxis (nose bleeds) YESNO
Seasonal allergies YESNO
Use dentures YESNO
Breast cancer YESNO
Breast biopsy YESNO
Lumpectomy / mastectomy YESNO
Cystic disorder YESNO
Joint pain YESNO
Joint swelling YESNO
Joint stiffness YESNO
Arthritis (OA) YESNO
Muscle pain YESNO
History of fracture YESNO
If yes, where?
Last bone density:
Coughing up blood YESNO
COPD (Emphysema) YESNO
Sleep apnea YESNO
Use CPAP at night YESNO
Angina / chest pain YESNO
Atrial fibrillation YESNO
Heart attack YESNO
Stents / angioplasty YESNO
Bypass surgery (CABG) YESNO
High cholesterol YESNO
Valve replacement YESNO
Congestive heart failure (CHF) YESNO
Lower extremity edema YESNO
Poor circulation YESNO
Pain / cramping in legs with walking YESNO
Abdominal pain YESNO
Nausea / vomiting YESNO
Vomiting blood YESNO
Blood in stool YESNO
Melena (black, tarry stool) YESNO
Diverticulosis / Diverticulitis YESNO
Gallbladder disease YESNO
Ulcers (stomach or intestine) YESNO
Heartburn / reflux (GERD) YESNO
Pain / burning with urination YESNO
Frequency of urination YESNO
Urgency of urination YESNO
Blood in urine YESNO
Frequent bladder infections (UTI) YESNO
STI: syphilis, gonorrhea, chlamydia YESNO
Decreased stream YESNO
Kidney disease YESNO
On dialysis YESNO
Rheumatoid arthritis YESNO
Lupus (SLE) YESNO
History of cancer: YESNO
If yes, type?
RIGHT-HAND DOMINANTLEFT-HAND DOMINANT
REASON FOR VISIT: RIGHTLEFT
HOW DID THIS PROBLEM OCCUR?
WILL YOU BE CLAIMING THIS INJURY UNDER WORKER'S COMPENSATION? YESNO
IS THIS A LIABILITY CASE? YESNO
HAVE YOU HAD TREATMENT FOR THIS? NOPHYSICAL THERAPYCORTICOSTEROID INJECTIONOTHER INJECTIONBRACEASSISTIVE DEVICE (CANE / WALKER / CRUTCHES / WHEELCHAIR / OTHER)
HAVE YOU TRIED ANY MEDICATIONS FOR THIS PROBLEM? NOYES,
STUDIES ALREADY PERFORMED FOR THIS PROBLEM: X-RAYMRICT SCANBONE SCANMYELOGRAMOTHER
PAST SURGICAL HISTORY: NONE
PHARMACY PHONE #:
ALLERGIES: NONEIODINE/BETADINEADHESIVEMYELOGRAM DYE OTHER:
FAMILY HISTORY: Please list age, general health, deceased or living.
QUIT YEARS AGO
YES, # OF PACKS/DAY AND # OF YEARS
ALCOHOL USAGE: NoneInfrequent1-2 drinks / week3-7 drinks / week7+ drinks / week
IMPORTANT: THIS IS NOT AN APPLICATION FOR CREDIT. CHARGES FOR ALL SERVICES RENDERED BY ORTHOPAEDIC SURGERY
ASSOCIATES (HEREINAFTER, "OSA") ARE DUE AND PAYABLE IN FULL FORTY-FIVE (45) DAYS FROM THE DATE SERVICES WERE
RENDERED. OSA will assist the Patient in the processing of insurance claims as a courtesy only. OSA accepts no responsibility for any
processing procedures, acts, omissions and/or neglect. PATIENT, RESPONSIBLE PARTY AND/OR INSURANCE CARRIER ARE SOLELY
RESPONSIBLE TO PAY FOR ALL SERVICES PROVIDED.
IN CONSIDERATION of the provision of services to the Patient named above, the Patient and the Responsible Party understand
and agree that:
1. Payment for services rendered is due in full forty-five (45) days from the date services were rendered, or as otherwise might be
stipulated through a contract between OSA and Patient's health plan or as stipulated by any state prompt payment laws. Any
balance unpaid after sixty (60) days from the date services were rendered will be considered "delinquent."
2. FOR PATIENTS WITH INSURANCE: In the event that services rendered are not covered or are deemed as not medically
necessary, Patient and/or Responsible Party shall be responsible for payment in full for those services. Patient and/or
Responsible Party shall also be responsible for any cost sharing, such as co-payments, coinsurance and/or deductibles.
3. In the event that any unpaid balance remains delinquent and has been placed for collection, the Patient and/or Responsible
Party must pay all costs of collection, including reasonable attorney's fees, if the delinquent balance is referred to an attorney for
4. In the event the Patient submits payment by check and that check is returned for INSUFFICIENT FUNDS by the bank, OSA
will add a bank charge to the balance owed by the Patient or Responsible Party.
5. No statement by an employee or agent of OSA will contradict, void or nullify this Agreement, nor shall the Patient rely on any
statement or opinions made by OSA that Patient's insurance carrier will pay the bill.
6. Patient also agrees to assign to OSA the rights under their policy of insurance, including medical benefits, the right to receive
information concerning benefits available, and the right to file a lawsuit to recover unpaid medical benefits for OSA's charges.
7. All patients who fail to arrive for their scheduled appointments or who cancel with less than 24 hours advance notice will be
charged a missed appointment fee of $25.00.
X-RAYS: Original X-rays are a part of the patient's permanent medical chart and remain in our office. If you would like a copy of
your X-rays, there is a nominal charge to cover the cost of duplication.
LIFETIME AUTHORIZATION - MEDICARE AND MEDICAID PATIENT CERTIFICATION - PATIENT CERTIFICATION
AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST: I certify that the information given by me in
applying for payment under Title XVIII and/or Title XIX of the Social Security Act is correct. I authorize any holder of medical or
other information about me to release to the Social Security Administration or its intermediary carriers, any information needed for
this or related Medicare or Medicaid claim. I request that payment of authorized benefits be made on my behalf. I assign the
benefits payable for physicians services. I understand that I am responsible for my health insurance deductibles and coinsurance.
Authorization is hereby given to OSA to submit my claim directly to my insurance on my behalf. I understand that by signing this
form, my signature is not needed each time a claim is submitted on my behalf. I further authorize my insurance carrier to forward
payment directly to OSA.
I HEREBY AUTHORIZE OSA TO RELEASE ALL MEDICAL AND BILLING INFORMATION NECESSARY TO SECURE
PAYMENT FROM MY DESIGNATED INSURANCE CARRIER ON MY BEHALF. I have read and fully understand all of the above
conditions. Once I sign this Agreement, I am responsible for all payments, charges, and if necessary, cost of collection as stated
above. I acknowledge receipt of copy of this Agreement.
Responsible Party (if other than Patient):
Relationship to Patient
DATE OF BIRTH:
1. I authorize Orthopaedic Surgery Associates to disclose my health information specific to the following date or time period
2. Individual or entity authorized to receive my health information:
3. Purpose for which disclosure is to be made:
4. Information to be disclosed:
Practitioner SummaryEmergency Room ReportX-ray RecordsHistory & Physical ExamLaboratory ReportConsultationOffice Chart NotesRadiology ReportRx
5. I understand that if the person(s) or entity that receives the information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may be redisclosed and is no longer protected by those regulations. Therefore, I release Orthopaedic Surgery Associates, its employees, and my physicians from all liability arising from this disclosure of my health information.
6. I understand that I may inspect or request copies of any information disclosed by this authorization. It is my understanding that this authorization will expire in 90 days from the date signed below. I understand that I may revoke this authorization by notifying, in writing, the Medical Records Department, knowing that previously disclosed information would not be subject to my revocation request.
7. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, or my eligibility for benefits
I certify that I have received a copy of Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Orthopaedic Surgery Associates' health care operations. The Notice of Privacy Practices also describes my rights and Orthopaedic Surgery Associates' duties with respect to my protected health information. The Notice of Privacy Practices is posted in the office of Orthopaedic Surgery Associates at 2828 South Seacrest Boulevard, Suite 204, Boynton Beach, FL and on Orthopaedic Surgery Associates' website at www.ortho-surgeon.com.
Orthopaedic Surgery Associates 2019
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