PLEASE COMPLETE IN INK Today`s Date: Patient Account

PLEASE COMPLETE IN INK
Today’s Date:
Patient Account #:
PATIENT NAME:
Referring Physician:
Primary Care Physician:
Other Treating Physicians:
Athletic Trainer / School:
(if a high school or collegiate athlete)
Date of Birth:
Age:
Height:
MEDICAL HISTORY:
No Medical Problems
DEXA Scan or Bone Density Scan
History of MRSA
Claustrophobic or fearful of enclosed spaces
Diabetes, Insulin-Requiring
Diabetes, Non-In sulin
Bleeding Disorder and/or Factor V, Factor VIII deficiency
Pulmonary Embolism (Blood Clot Lung)
Deep Vein Thrombosis (Blood Clot Leg)
Thyroid Disorder
HIV or AIDS
Leukemia or Lymphoma
Organ Transplant
Heart Attack
Coronary Artery Disease / Heart Disease
Heart Arrhythmia
Pacemaker
Heart Murmur
Stroke or Ministroke
High Blood Pressure
Asthma
Emphysema or COP D
Pneumonia
Tuberculosis
Malignant Hyperthermia
Weight:
Peripheral Vascular Disease
Hiatal Hernia/Reflux Disease
Peptic Ulcer Disease
Diverticulitis
Urinary Tract Infections
Kidney Stones
High Cholesterol
Osteoporosis
Fibromyalgia
Seizure Disorder
Gout
Osteoarthritis
Rheumatoid Disease
Migraine Headaches
Cancer (type)
Hepatitis
Liver Disease
Psoriasis or Other Skin Disease
Poliomyelitis
Psychiatric Disorder
Anxiety Disorder
Depression
Drug Addiction
Glaucoma
Dialysis / Renal Failure
Reflex Sympathetic Dystrophy (CRPS)
Please list any other conditions not mentioned above:
PAST SURGICAL HISTORY: Please list any operations you have had in the past & date or approximate age at time of procedure
Date or Age
No Previous Surgery
Fracture without Surgery
Fracture with Surgery
Shoulder Surgery
Hand Surgery
Spine Surgery
Knee Surgery
Foot/Ankle Surgery
Total Hip Arthroplasty
Total Knee Arthroplasty
Heart Related Surgery
Appendectomy
C-Section
Gall Bladder
Hernia Repair
Hysterectomy
Tonsillectomy/Adenoidectomy
Please list any additional surgeries:
Operation
Date or Age
250 Cetronia Road • Allentown, PA 18104 • Phone: 610-973-6200 • www.oaaortho.com
Lehighton: 1241 Blakeslee Blvd. Dr. E. ● Lehighton, PA 18235 ● 570-386-9910
Bethlehem: 2901 Emrick Blvd. ● Bethlehem, PA 18020 ● 610-973-6200
MEDICATIONS:
Please list all medications or drugs including birth control pills, over-the-counter medications or herbal
supplements you are currently taking
None
Drug or Medicine
ALLERGIES:
Amount/Dose
Start Date
Stop Date
Stop Reason
Please list all medications, metals, dyes, latex or foods. If you have a paper list of your medications or allergies,
we will make a photocopy of them.
No Known Drug Allergies
Allergy List
Reaction
FAMILY HISTORY: Do any of these diseases run in your immediate family - Mother (M) Father (F) Sister (S) Brother (B)? Mark box and indicate relationship.
No Medical Conditions M F S B
Asthma M F S B
Back Problems M F S B
Cancer M F S B
Diabetes Insulin Dependent M F S B
Diabetes Non-Insulin Dependent M F S
SOCIAL HISTORY:
Marital Status:
Married
Number of children?
Single
Heart Disease M F S B
High Blood Pressure M F S B
Orthopaedic Problems M F S B
Rheumatoid Arthritis M F S B
Stroke M F S B
Other
B
Divorced
Separated
Widowed
Domestic Partner
Yes
No
Do you smoke?
If yes, how many packs a day?
If yes, age started
If you are a past smoker, when did you quit & amount previously smoked?
Do you use chewing tobacco?
Do you use alcohol?
Occasional
Moderate
Heavy
No
Yes
No
If yes, how many tins/pouches?
Do you use caffeine?
Occasional
Moderate
Heavy
No
How many years?
Do you exercise?
Occasional
Moderate
Heavy
No
Abused Prescription Drugs
Used Recreational Drugs
Used Anabolic Steroids
Used Other Performance Enhancing Substances
Recreational Activities (sports, hunting, fishing, gardening hobbies, etc.)
Education
Less than 8th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
2 Year College
4 Year College
Post Graduate
OCCUPATIONAL HISTORY:
What statement describes your current employment situation (check all that apply)?
Retired (not due to health)
Currently Working
Unemployed
Homemaker
On Unpaid Leave
On Paid Leave
Disabled
Employer:
What is your primary occupation (if not working, what was your primary occupation)?
How many years have you been with your current employer?
If not working, how long has it been since you stopped?
Is there litigation in process pertaining to your symptoms?
Yes
No
Date:
Patient Name:
REVIEW OF SYSTEMS: Have you had any of the following in the past six (6) months?
DOB:
Please circle all that apply.
I have had no problems with any body part for the past 6 months.
(Stop, no additional info needed.)
None
CONSTITUTIONAL (General)
Constitutional: fever, night sweats, weight gain (______lbs), weight loss (______ lbs), exercise intolerance
EYES
Eyes: dry eyes, irritation, vision change
ENMT (Ears, Nose, Mouth, Throat)
Ears: difficulty hearing, ear pain
Nose: frequent nosebleeds, nose/sinus problems
Mouth/Throat: sore throat, bleeding gums, snoring, dry mouth, oral abnormalities, mouth ulcer, teeth abnormalities,
mouth breathing
CARDIOVASCULAR
Cardiovascular: chest pain on exertion, arm pain on exertion, shortness of breath when walking, shortness of breath
when lying down, palpitations, known heart murmur, light-headed on standing
RESPIRATORY
Respiratory: wheezing, shortness of breath, coughing up blood, sleep apnea
GASTROINTESTINAL
Gastrointestinal: abdominal pain, vomiting, change in appetite, black or tarry stools, frequent diarrhea, vomiting blood
GENITOURINARY
Genitourinary: urinary loss of control, difficulty urinating, increased urinary frequency, hematuria (blood),
incomplete emptying
MUSCULOSKELETAL
Musculoskeletal: muscle aches, muscle weakness, arthralgias/joint pain, back pain
INTEGUMENTARY (Skin)
Skin: abnormal mole, jaundice, eczema, rash, itching, dry skin, growths/lesions
NEUROLOGIC
Neurologic: loss of consciousness, weakness, numbness, seizures, dizziness, frequent or severe headaches,
migraines, restless legs
PSYCHIATRIC
Psych: depression, mania, sleep disturbances, restless sleep, feeling unsafe in relationship, alcohol abuse
ENDOCRINE
Endocrine: fatigue, increased thirst, hair loss, increased hair growth, cold intolerance
HEMATOLOGIC/LYMPHATIC
Hematologic/Lymphatic: swollen glands, easy bruising, excessive bleeding
ALLERGIC/IMMUNOLOGIC
Allergy/Immunologic: runny nose, sinus pressure, itching, hives, frequent sneezing
OAA
Patient Request for Confidential Communications
Orthopaedic Specialists
Patient:
Address:
Patient No.:
Soc. Sec.:
Phone:
Date of Birth:
Please consider this a request for confidential communication of my protected health information (PHI).
I understand that you will do your best to reasonably accommodate it.
Check all that apply to this request:
Please do not phone me at home. Use the following alternative phone number to contact me:
______________________.
Please do not phone me at work. Use the following alternative number to contact me:
______________________.
Please send my mail, including my bills, to this alternative address:
________________________________________________________
________________________________________________________
________________________________________________________
Please do not leave messages on my answering machine/voice mail.
Please do not mail appointment cards to me.
Please do not contact me by email.
Other requests (describe in detail)
Please release medical and billing information to:
________________________________________________________
________________________________________________________
________________________________________________________
_______ (initial) I understand that the physician or provider to whom I am making this request
will make reasonable efforts to accommodate this request. I further understand that in some
emergency situations, my PHI may be released.
I acknowledge that I have received the Notice of Privacy Practice for OAA-Orthopaedic
Specialists. OAA-Orthopaedic Specialists is authorized to use and disclose health information
for treatment, payment and healthcare operations purposes consistent with its Notice of
Privacy Practices.
Note: Please print all information except signature.
Patient:
Signature of Patient (or patient’s personal representative): ________________________________
Date representative: ________________________________
Name of personal representative: ________________________________
Relationship to patient (or other authority): ________________________________
FINANCIAL POLICY
Patient ID#: ___________________
Thank you for choosing OAA Orthopaedic Specialists as your orthopaedic specialty healthcare provider. We are
committed to providing you and your family with the best available medical care. In our ongoing process to make sure
that all of your medical needs are met, our staff will be available to discuss our fees and this policy with you. The
Services you have elected to participate in means that you accept a financial responsibility on your part.
We ask that all responsible parties read and sign our financial policy as well as complete the patient information
forms prior to seeing the physician.
Payments for all services will be due at the time services are rendered. In order to serve you better, we accept
cash, check, Visa and MasterCard. As a courtesy to you, we will verify your coverage and bill your insurance
carrier on your behalf; however, you are ultimately responsible for the entire bill. The only exception to patient
responsibility for payment is for an appointment for employer requested work performance screenings.
As the responsible party, please understand:
1. Your insurance policy is a contract between you, your employer (if applicable), and the insurance company.
We are not a party to that contract. Our relationship is with you, not your insurance company. We will not
become involved in disputes between you and your insurer regarding deductibles, co-payments, covered
charges, secondary insurance and “usual and customary” charge. As your medical provider, we will only
supply factual information to facilitate claim processing.
2. If your insurance requires a referral for you to see an OAA Orthopaedic Specialists provider, it is your responsibility
to provide our office with the referral. If your insurance company denies payment due to no referral, you, the
patient, agree to pay OAA Orthopaedic Specialists in full for any charges incurred during your visit.
3. Fees for services, which include unpaid balances, deductibles, co-payments and in some cases coinsurance, are
due at the time of service. Returned checks and unpaid balances may be subject to collection placement and
collection fees.
4. All charges are your responsibility whether your insurance company pays or does not pay. If your insurance carrier
does not remit payment within sixty days, the balance may be due in full from you. If any payment is made directly
to you for services billed by OAA Orthopaedic Specialists, you recognize an obligation to promptly remit payment to
OAA Orthopaedic Specialists.
5. I understand and agree that if I fail to make any of the payments for which I am responsible in a timely
manner, after such default and upon referral to a collection agency or attorney by OAA Orthopaedic
Specialists, I will be responsible for all costs of collecting monies owed, including collection agency fees.
6. The above does not apply for those patients that are considered Workers’ Compensation. However, be
advised that as a compensation patient you may be held responsible for charges in the event that your
claim is denied or not paid or determined not to be work related.
7.
Our practice utilizes the services of Assistant Surgeons/Physician Assistants for medical services including
surgical procedures. As with the other professional services, we will bill your insurance for these services;
however, should your insurance not cover the charges, you may be held ultimately responsible.
8.
The completion of disability and/or FMLA forms are not billable/reimbursable by insurance carriers, therefore
fees are your responsibility for payment. OAA Orthopaedic Specialists fees related to completion of these
documents is $10.00 which is expected to be paid upon presentation of forms for completion. Please allow 10 to
14 business days for completion of these forms.
9.
If you need to cancel your scheduled appointment, OAA asks that you contact our office at least 24 hours in
advance. OAA reserves the right to apply a $50 fee for any appointment not cancelled within the requested 24
hour timeframe.
We understand that financial problems may affect timely payment, so we encourage you to communicate any such
problems to us, so that we may assist you in keeping your account in good standing. Our financial counselor is
available to assist you or answer any questions you may have.
INSURANCE RELEASE INFORMATION
I HEREBY AUTHORIZE THE OFFICE OF OAA ORTHOPAEDIC SPECIALISTS TO RELEASE TO MY INSURANCE
COMPANY ANY NECESSARY INFORMATION NEEDED TO FILE AND EXPEDITE PAYMENT ON MY CLAIM. I
FURTHER ASSIGN ANY BENEFITS PAYABLE ON MY BEHALF TO OAA ORTHOPAEDIC SPECIALISTS. I UNDERSTAND I
AM FINANCIALLY RESPONSIBLE FOR ANY BALANCE NOT COVERED BY MY INSURANCE CARRIER.
I UNDERSTAND THE ABOVE INFORMATION AND WILL BE RESPONSIBLE FOR THE PATIENT
LISTED BELOW
Printed Name of Patient
Signature of Patient or Responsible Party
Relationship if Other than Patient
Date of Birth
Date
Patient Name: ______________________________________
Date of Birth: _________________
Dear Patients,
Your medical provider is participating in a government program that encourages the adoption
of electronic health records. This technology will lead to reduced health care costs but it will also
improve the quality of your care and our ability to communicate with you, our patients.
As part of this program, the government requires us to record the following demographic information
about you:
 Preferred language
 Race
 Ethnicity
 Date of birth
 Gender
The U.S. Centers for Disease Control and Prevention (CDC) provides the options for the race and
ethnicity fields that match the data collection standards defined by the U.S. Office of Management
and Budget (OMB) and the U.S. Bureau of the Census (BC). We maintain secure records and
assure you that this information will remain confidential.
You can help us by reviewing the list of options below and providing your race and ethnicity
information during registration or check-in. If you do not wish to provide this information, you may
simply decline.
Thank you for your assistance!
OAA Orthopaedic Specialists
Please specify your preferred language:
English
Spanish
Other ______________
Please identify your Race from the following CDC-defined options:













African
African American
Alaska Native
American Indian
American Indian
or Alaska Native
Arab
Asian
Asian Indian
Bahamian
Bangladeshi
Barbadian
Bhutanese
Black
 Black or African
American












Burmese
Cambodian
Chinese
Dominica Islander
Dominican
European
Fillipino
Haitian
Hmong
 Japanese
 Korean
 Laotian
 Madagascar
 Malaysian
 Maldivian
 Melanesian
 Micronesian
 Middle Eastern
or North African

ative Hawaiian or
N
Other Pacific Islander


Nepalese
Indonesian
Iwo Jiman
Jamaican
Okinawan
 Other Pacific
Islander












Other Race
Pakistani
Polynesian
Singaporean
Sri Lankan
Taiwanese
Thai
Tobagoan
Trinidadian
Vietnamese
West Indian
White
Please identify your Ethnicity from the following CDC-defined options:



Central American
Cuban
Dominican
 Hispanic or Latino/Spanish 
 Latin American/Latin,

Latino

Mexican
Not Hispanic or Latino
Puerto Rican


South American
Spaniard