New Patient – Appointment Information This appointment is for the consultation only. Procedure appointments will be scheduled at a different time and location. If you have any films, please remember to bring them with you. The appointment has been scheduled at our office located at: 6464 SW Borland Rd., Suite A-2, Tualatin, OR 97062 We request a 24 hour notice if you need to cancel or reschedule your appointment, otherwise a $50.00 late cancellation charge will apply. Our office has enclosed new patient forms for you to complete and bring with you to your visit. Your initial consult/evaluation can last up to 1 hour. We ask that you keep this in mind when making arrangements for your appointment. If you have any questions or concerns regarding your appointment, please contact our office at (503) 885-1515. Patient Name: Appointment Date: Check In at: Appointment Time: Select your provider: Robert D. Heros, M.D. Jason G. Anderson, D.O. Tyler G. Huntington, PA-C Ayumi Mizuno, AGNP-C Patient Information Please use an ink pen Today’s Date: Full Name: Date of Birth: Sex: Male Female Address: Telephone: City: State: ZIP Code: SSN: Employer: Employer Telephone: Mobile Phone: Marital Status: Select... Married Single Divorced Widowed Partnered Spouse/Partner's Name: Spouse/Partner's Phone #: Preferred Language: Ethnicity: Hispanic/Latino: Yes No Email: Emergency Contact – Nearest relative other than spouse Name: Relationship: Telephone: Address: City: State: ZIP Code: Referring Physician or Source of Referral Referring Physician’s Name: Telephone: Address: City: State: ZIP Code: Family Physician Family Physician’s Name: Telephone: Address: City: State: ZIP Code: Other Consulting Physicians: Insurance Information Is this appointment related to a work injury, motor vehicle or personal injury? Yes No Primary Insurance Insurance Company: Telephone: Address: City: State: ZIP Code: Insured’s Name: Date of Birth: Sex: Select Male Female Policy / ID #: Group Name / #: Employer: Secondary Insurance Insurance Company: Telephone: Address: City: State: ZIP Code: Insured’s Name: Date of Birth: Sex: Select Male Female Policy / ID #: Group Name / #: Employer: If your appointment is due to work-related injury or condition Claim # or ID #: Date of Injury: Employer (where claim was filed): Employer Phone: Insurance Carrier: Carrier Phone: Claims Examiner/Contact: Examiner Phone: Insurance Address: City: State: ZIP: What injuries did you sustain? If your appointment is due to an auto accident or personal injury Date of Injury: State in which accident occurred: Insurance Company: Insurance Phone: Insurance Address: City: State: ZIP: Insured's Name: Policy #: Attorney’s Name: Attorney Address: City: State: ZIP: Release of Information and Payment Authorization All other insurance companies and/or third party payers: I HEREBY AUTHORIZE Spinal Diagnostics Robert D. Heros, M.D., Jason G Anderson, D.O., Tyler G. Huntington, PA-C, Ayumi Mizuno, AGNP-C and/or any of their representatives to submit a claim to my insurance carrier or its intermediaries for all services rendered by the physician(s) and authorize and direct my insurance carrier or its intermediaries to issue payment directly to the physician(s) rendering the service. I authorize the release of any and all medical information to my insurance carrier or it intermediaries for services rendered. Medicare: I certify that the information given by me in applying for payment under title XVIII 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, Medicare, Medicaid, or its intermediaries or carriers any and all information needed for this or a related Medicare claim. I authorize and request that payment be made directly to Spinal Diagnostics, or their representative. Guarantee of Payment: I UNDERSTAND that filing a claim with my insurance company or other third party payor, under any circumstance, does not relieve me from my responsibility for the payment of all charges. I further acknowledge that I am responsible for the payment of all charges for services rendered by Spinal Diagnostics (Dr. Heros, Dr. Anderson, Tyler Huntington, PA-C, Ayumi Mizuno, AGNP-C)to me. I understand that it is ultimately my responsibility to verify my insurance benefits, eligibility and authorization requirements prior to any scheduled appointments. By signing this document I personally guarantee the payment of these charges for medical services rendered. This includes, but is not limited to, claims filed for Worker’s Compensation, automobile accidents and/or personal injuries. If the patient is involved in a motor vehicle or liability accident, the patient is responsible for paying all medical costs even if there is a pending lawsuit. Payment must be made in full within 30 days of being billed unless prior arrangements have been made. I agree that this authorization shall remain valid until rescinded in writing or replaced. Acknowledgment of Receipt of Privacy Notice I acknowledge that I have received the attached Privacy Notice. Patient Signature Signature of Patient or Legal Representative: Clear Signature Please Print Name: If signed by legal representative, indicate relationship to patient: Financial Policy Welcome to Spinal Diagnostics. Please take a moment to review our Payment Policies. You may receive more than one charge for an appointment with our office. We require patients to provide a copy of their insurance card, proof of Identification and co-payment at check-in for every visit. If you do not have your insurance card, photo ID or co-payment with you at the time of your visit your appointment may be rescheduled. Patient Responsibility Patients are responsible for all charges resulting from treatment provided by Spinal Diagnostics. Payment is due in full within 30 days of receiving your first statement unless other financial arrangements have been made with the Billing Coordinator. Please remember your insurance policy is an agreement between you and your insurance company, and it is ultimately your responsibility to pay for any balance not paid or covered by your insurance company. This includes your Motor Vehicle Coverage and Worker's Compensation Coverage. Required Patient Deposits – Patients Without Insurance We do offer a 30% discount for patients who do not have insurance. Patients will be required to pay in full at the time of their appointment. Fees will be based on provider billing and provided after the office visit. Co-payments, Deductibles and Co-insurance Co-payments are the amounts your insurance policy requires us to collect with each visit and are due at the time of service. Patients who arrive without their co-pay, may be rescheduled. We accept cash, check and most major credit cards. You are welcome to pay through our online payment system at onpatient.com. Payment Arrangements All patients will be required to pay their balances within 30 days of receiving their first statement unless payment arrangements have been made with Spinal Diagnostics. Please contact our Billing Coordinator at 971-228-2079 as soon as possible after receiving your statement if payment arrangements are needed. Insurance Billing As a courtesy we will bill your primary insurance, secondary insurance, Motor Vehicle Accident, and Worker’s Comp. claim for you. However, primary responsibility for the account is yours. Providing correct insurance billing information is the responsibility of the patient. If your insurance changes, please present your new card at your visit. All of our providers are participating with Medicare. If you have Motor Vehicle Accident or Workers Comp claims please provide the adjuster’s name, contact number, claim number and the date of incident. If you do not have your insurance card with you at the time of your visit to provide us with valid insurance information, you will be billed for the services, or your appointment rescheduled. Cancellation and Reschedule Fee If you need to cancel or reschedule your office visit, you must notify us at least 1 business day prior to your office visit time. You may be charged a $50 cancellation/reschedule fee for insufficient notice. If you arrive 10 minutes or more after your scheduled appointment time, you may be charged a cancellation fee and rescheduled. No Show Fee You may be charged a $50 fee for not showing to your scheduled office visit. If you have a pattern of no-shows, frequent reschedules and/or late cancellations, you may be dismissed from Spinal Diagnostics. Past Due and Collections Accounts We reserve the right to send accounts with balances that have been outstanding over 90 days from the date of service or the date of payments received from your insurance company, whichever is more, to a collection agency. If you have a balance on your account that is more than 60 days old, and over $300, you will be referred to the Spinal Diagnostics Billing Coordinator to make payment arrangements. If any portion of your past due amount has been assigned to a collection agency you will need to pay 100% of the balance before your appointment can be scheduled. The patient's signature (or signature of the patient’s parent or legal guardian) acknowledges that you understand and accept the above information. I have read the above Financial Policy and agree with the terms of this agreement. Financial Policy Agreement By signing below, I acknowledge I have read and agree to the terms stated in the financial policy. Clear Signature Printed Name: Authorization to Disclose Personal Health Information Please complete this form to allow Spinal Diagnostics to share your personal health information with trusted individuals. 1. Voicemail Authorization May we leave detailed voicemail messages regarding your health information? Yes, at this phone number: Area Code: - Phone Number: No, please only leave a message asking me to call back. 2. Authorized Person 1 Full Name: Phone: What can we disclose to this person? ANY information LIMITED information Appointment information Other specific information: 3. Authorized Person 2 Full Name: Phone: What can we disclose to this person? ANY information LIMITED information Appointment information Other specific information: 4. Acknowledgment By signing this form, I authorize Spinal Diagnostics to disclose my personal health information to the individuals listed above. I understand that my information may be re-disclosed and may no longer be protected by law. I also understand that I may revoke this authorization at any time, in writing, except to the extent that action has already been taken based on this permission. Your Initials (used in all fields): Signature: Clear Signature AUTHORIZATION TO OBTAIN & DISCLOSE HEALTH INFORMATION I authorize the use or disclosure of the individual’s health information named below to be used or disclosed as follows: Patient Name: Alias or Other Names Used: Date of Birth: Please OBTAIN information FROM the following: Name & Title of Provider/Organization Name: Street Address/Fax: City, State, Zip: Please SEND my health information TO: Name & Title of Provider/Organization Name: Street Address/Fax: City, State, Zip: For the purpose of: Patient Care Self/Personal Records Other: Description of Nature of Information to Be Used and/or Disclosed: Most recent 2yrs of records Clinician office notes History & Physical Exams X-ray & imaging reports Consultations Lab reports All Clinic records Billing statements Records for the following dates of treatment: Other (specify): List specific dates of records to be released: The following (*) must be initialed by the patient to be included: Please enter your initials: * HIV/AIDS related information and/or records * Mental Health information * Psychotherapy notes * Genetic Testing information ** Drug/Alcohol information **Federal regulation requires a description of how much and what kind of information will be disclosed. DURATION / RESTRICTIONS / RIGHTS DURATION: This authorization shall begin immediately and remain in effect until notified otherwise. RESTRICTIONS: I understand that the information released may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws or regulations. RIGHTS: I understand that I may refuse to sign this authorization and that my refusal to sign may not affect my ability to obtain treatment. I may inspect or copy any information to be used and/or disclosed under this authorization in accordance with organizational policy and Spinal Diagnostics has up to 30 days to comply with my written request. I understand that I have the right to revoke this authorization by sending a written statement to the clinic manager of the disclosing location listed above. My revocation will be effective upon receipt, but will not be effective to the extent that this organization has taken action in reliance upon this authorization. Authorization Signature of Patient or Legal Representative: Clear Signature If signed by legal representative, name & relationship to patient: Health History Patient Name: Date of Birth: Who referred you to us? Occupation: Primary Care Provider: Workman’s Comp Claim Motor Vehicle Accident Do you have a lawyer? Yes No Is English your primary language? Yes No If no, which language? In the past 2 weeks, have you experienced any of the following? Fever Chills Night Sweats Insomnia Involuntary Weight Loss Headache Sore Throat Visual Difficulty Ringing In Ear Seizures/Tremors Sinus Congestion Chest Pain Palpitations Wheeze/Cough Nausea/Vomiting Stomach Pain Diarrhea Rash Blood In Urine/Stool Easy Bruising Joint Pain/Swelling Swelling Excessive Thirst/Appetite Fainting Recent Bleeding Shortness of Breath Loss of Bowel/Bladder Control Hearing Loss Pain History Date of onset of present pain: Cause of Pain Motor Vehicle Accident Accident at Work Accident Away from Work Sports Unknown Cause Other Pain Location Left Side Right Side Both Sides Headache Neck Shoulder Leg/Foot Arm/Hand Chest Upper Back Mid Back Abdomen Low Back Buttock Other Pain Quality Burning Throbbing Aching Stabbing Numbness Tingling Weakness Shooting Dull Sharp Other Pain Duration Occasional Off and On Quick/Shooting Frequent Daily Constant Activities That Make Pain Worse Sitting Standing Walking Bending Forward Arching Backwards Rotational Movement Driving Rest/Sleep Times of Pain In The Morning In The Evening With Certain Movements During Rest During or After Activity Activities That Make Pain Better Sitting Standing Walking Movement Lying Down Leaning Forward Leaning Back Heat Ice Rest Other Medical History Patient Name: Date of Birth: Height: Weight: Neurological History Seizures: Yes No Stroke/TIA: Yes No Glaucoma Numbness/Weakness/Paralysis Bell’s Palsy Parkinson’s Dementia Neurologist: Ophthalmologist: Skin Open Wounds/Breaks in Skin Rashes History of Cold Sores/Shingles/Herpes Dermatologist: Cardiovascular Heart Attack (MI): Yes No Chest Pain (Angina) Irregular Heart Rate/Rhythm/Pacemaker High Blood Pressure Bleeding Disorder: Anticoagulant Treatment Cardiologist: Anticoagulant Management: Gastrointestinal / Genitourinary Heartburn/GERD/Reflux/Hiatal Hernia Kidney Disease: Hepatitis/Liver Function Colitis/Other Abdominal Problems Gastroenterologist: Nephrologist: Respiratory Shortness of Breath Asthma or Wheezing/Inhaler Snoring/Sleep Apnea/Difficult Airway Emphysema/COPD Chronic/Frequent Bronchitis or Pneumonia Tuberculosis (TB) Pulmonologist: Endocrine / Immune System Diabetic Type 1 Type 2 Avg AM Level: Thyroid Problems HIV/AIDS Endocrinologist: Muscle / Skeletal Osteoporosis Use of a Cane/Wheelchair/Walker Other MRSA Infection: Cancer/Chemo: Oncologist: Serious problems with any prior anesthetics Family history with serious anesthesia problems Infection/Illness in past 6 months: Yes No Explain: Current, or Date Resolved: Other medical problems or comments: When was your last vaccination/flu shot? Lifestyle Do you smoke? Yes No # Years Smoked: # Packs/Day: Former Smoker - Year Quit: Do you drink alcohol? drinks/week Treated for drug/alcohol dependency? Yes No Currently Pregnant? Yes No Date of last period: Menopause Hysterectomy OFFICE USE ONLY Initials 1: Date 1: Initials 2: Date 2: Initials 3: Date 3: Initials 4: Date 4: Initials 5: Date 5: Initials 6: Date 6: Previous Treatments for This Pain Patient Name: Date of Birth: Physical Therapy Effectiveness: Select Never Tried Not Helpful Minimally Helpful Somewhat Helpful Helpful Where? How long / Last Treatment: Other Treatments Chiropractic Care: Select Never Tried Not Helpful Minimally Helpful Somewhat Helpful Helpful Massage: Select Never Tried Not Helpful Minimally Helpful Somewhat Helpful Helpful Acupuncture: Select Never Tried Not Helpful Minimally Helpful Somewhat Helpful Helpful Spine Injections: Select Never Tried Not Helpful Minimally Helpful Somewhat Helpful Helpful Spine Surgery: Select Never Tried Not Helpful Minimally Helpful Somewhat Helpful Helpful Medications / OTC Pain Meds: Select Never Tried Not Helpful Minimally Helpful Somewhat Helpful Helpful Diagnostic Imaging MRI – Where: Approx Date: CT – Where: Approx Date: X-ray – Where: Approx Date: Medications and Allergies Preferred Pharmacy: City: Phone: Current Prescription and OTC Medications Please list medications: 1. Medication: OTC/Prescription: 2. Medication: OTC/Prescription: 3. Medication: OTC/Prescription: 4. Medication: OTC/Prescription: 5. Medication: OTC/Prescription: Medication Allergies Please list allergies: 1. Substance: Reaction: 2. Substance: Reaction: 3. Substance: Reaction: 4. Substance: Reaction: 5. Substance: Reaction: Check any of the following that apply: No known drug allergies Tape/Adhesives Latex Iodine/Contrast Dye Shellfish Previous Surgeries Please list all previous surgeries below: 1. Surgery: Year: 2. Surgery: Year: 3. Surgery: Year: 4. Surgery: Year: 5. Surgery: Year: Send completed form to this email: Submit
