New Patient Intake Forms - Camelback Spine Care

  • Patient Info
  • Insurance & Claim
  • Symptoms
  • Diagnostic & History
  • Medication & History
  • Review of Symptoms & Consent for Treatment
  • Financial Policy
  • Authorized Parties & Authorization

Patient Information

Preferred Pharmacy

Primary Insurance Plan

Complete this box if you are not the policy holder for your primary insurance

Secondary Insurance Plan (if any)

Complete this box if you are not the policy holder for your primary insurance

Workers Compensation Claim Information

Complete this section only if your visit today is related to Workers Compensation claim.

Injury Claim

Onset of Symptoms

"N" = Numbness
"S" = Stabbing
"B" = Burning
"P" = Pins and Needles
"A" = Aching

Pain Description - Check all of the following that describe of your pain :

Pain Freqyuency

Mark all of the following activities that are adversely/negatively affected by your pain

In the past three months have you developed any new:

Diagnostic Tests and Imaging

Pain Treatment History

Mark all of the following pain treatments you have undergone prior to today's visit:

Anesthesia History

Past Surgical History

Please indicate any surgical procedures you have had done in the past, including the date, type and any pertinent details.

Current Medication

# Medication Name Dose Frequency
1
2
3
4
5
6
# Medication Name Dose Frequency
7
8
9
10
11
12

Allergies

Medication Name Allergic Reaction Type

Family History

Arthritis Cancer Diabetes Headaches Heart Disease High Blood Pressure High Cholesterol Kidney Problems Liver Problems Osteoporosis Rheumatoid Arthritis Seizures Stroke
Mother
Father

Social History



Past Medical History

Review of Symptoms

Medical History and Consent for Treatment

I certify that the above information is accurate, complete and true.

I authorize Camelback Spine Care and any associates, assistants, and other health care providers it may deem necessary, to treat my condition. I understand that no warranty or guarantee has been made of a specific result or cure. I agree to actively participate in my care to maximize its effectiveness. I give my consent for Camelback Spine Care to retrieve and review my medication history. I understand that this will become part of my medical record.

I acknowledge that I have had the opportunity to review Camelback Spine Care Notice of Privacy Practices, which is displayed for public inspection at its facility and on its website. This Notice describes how my protected health information may be used and disclosed, and how I may access my health records.

I authorize the Camelback Spine Care to release my Protected Health Information (medical records) in accordance with its Notice of Privacy Practices. This includes, but is not limited to, release to my referring physician, primary care physician, and any physician(s) I may be referred to. I also authorize Camelback Spine Care to release any information required in obtaining procedure authorization or the processing of any insurance claims.

I understand that Camelback Spine Care will not release my Protected Health Information to any other party (including family) without my completing an Authorization for Use and Disclosure of Protected Health Information" form, available at its facility and on its website. This agreement can be revoked by me at any time with written notification and is valid until revoked. Payment in full is expected within 30 days of being notified of any balance due. Please note that in the event that you fail to make payment when due, this account will be referred to a collection agency for collections. In that event, the contingency fee assessed by the collection agency will be added to the principal and interest due. You will be additionally liable for attorney fees. Both collection agency fees and attorney fees will increase the balance owed.

Financial Policy

Camelback Spine Care believes that part of good healthcare practice is to establish and communicate a financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policy.

1.PAYMENT- is expected at the time of your visit. (This includes Copayments, Deductibles, Coinsurance, Missed Appointments, Procedure Prepayment; unpaid balance after insurance has paid their portion, Past Due, etc.). If you are unable to make a full payment Camelback Spine Care reserve the right to reschedule your appointment for a later time when you are able to make your full payment, (any payment due or owed at time of service). If a prepayment is made for any services and a refund is due after insurance processes, any outstanding balance on your account will be deducted before issuing your refund. We will accept cash, check, or credit card. Payment will include any unmet deductible, co-insurance, co-payment amount, or non-covered charges from your insurance company. If you do not carry insurance, or if your coverage is currently under a pre-existing condition clause, payment in full is expected at the time of your visit. We do ask for a copy of an ID card or license and insurance cards.

2.INSURANCE- We are participating providers with several insurance plans. We will file all of these insurance claims. A list of these insurance plans is available upon request. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. If your insurance company does not pay the practice within a reasonable period of time, you will be billed. If we later receive payment for your insurer, we will refund any overpayment to you.

If our providers are not listed in your plan's network, you may be responsible for partial or full payment. If you are insured by a plan with which we have no prior arrangement, we will prepare and send the claim in for you on an unassigned basis. This means the insurer may send the payment directly to you and therefore, our charges for you are due at the time of service. Due to the many different insurance products out there, our staff cannot guarantee your eligibility and coverage. Be sure to check with your insurer's member benefits department about services and physicians before your appointment. Many web sites have erroneous information and are not a guarantee of coverage. You are responsible for obtaining a properly dated referral, prior authorization if required by your insurer and responsible for payment if your claim is rejects for the lack of one.

Not all insurance plans cover all services. In the event your insurance plan determines a service to be "not covered", you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office. All procedures billed in this office are considered covered unless limited by your specific insurance policy.

Camelback Spine Care only has a specific amount of time to submit a claim to your insurance carrier. If your coverage/insurance company changes and we bill your old carrier we may miss the time limit to process the claim. In this case, the claim becomes your responsibility for payment, so please notify us immediately if your coverage changes so that we can accurately submit the claims.

3.COLLECTION- If you have an outstanding balance over 120 days old and have failed to make payment arrangements (or become delinquent on an existing payment plan), we may turn your balance over to a collection agency and/or an attorney, which may result in reporting to credit bureaus and/or legal action. Camelback Spine Care reserves the right to refuse treatment to patients with outstanding balances over 120 days old. You agree to pay Camelback Spine Care for any expenses we incur to collect on your account, including attorney fees, collection fees, and contingent fees to collection agencies that can be more than 35% of the delinquent balance. Contingency fees will be added and assigned to the collection agency immediately upon our referral of your account to the collection agency of our choice. You agree that in order for us to service your account or to collect any amounts you may owe, we may contact you by phone at any number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using pre-recorded voice messages and/or use of an automatic dialing device.

4.RETURNED CHECKS- will incur a $40.00 service charge. You will be asked to bring cash, certified funds or a money order to cover the amount of the check plus the $40 service charge to pay the balance prior to receiving services from our staff or the physician. Stop payments or overturned chargebacks on your credit card constitute a breach of payment and are subject to the $40 service fee and collections action. All bad checks written to this office are subject to collections and will be prosecuted in Maricopa County.

5.ACCOUNTING PRINCIPALS- Payment and credits are applied to the oldest charges first, except for insurance payments which are applied to the corresponding dates of service.

6.FORMS AND CONSULTS FEES-Completing insurance forms, copying medical records, etc... requires office staff time and time away from patient care for our doctors. We require pre-payment for completing forms, copying medical records, notarizing, or for extra written communication by the provider. The charge is determined by the complexity of the form, letter, or communication. On occasion, our staff may be asked to provide a deposition and/or other testimony or actions concerning your care. There is a separate fee schedule for such activity. The fees for such activity are to be paid by the patient regardless of the party requesting the activity.

7.CANCELLATIONS OR MISSED APPOINTMENTS- If you do not cancel your appointment at least 24 hours before, or if you no-show, we may assess you a $35.00 missed appointment fee. If you do not cancel your procedure with at least 24 hours' notice, you may be assessed a $500.00 missed procedure fee. Multiple missed visits may result in discharge from the practice.

8.RESPONSIBILITY FOR PAYMENT- I understand that I, personally, am financially responsible to Camelback Spine Care for charges not covered by the assignment of insurance benefits.

9.ASSIGNMENT OF INSURANCE BENEFITS- I hereby assign, transfer, and set over directly to Camelback Spine Care sufficient monies and/or benefits for basic and major medical to which I may be entitled for professional and medical care, to cover the costs of the care and treatment rendered to myself or my dependent in said practice. I authorize Camelback Spine Care to contact my insurance company or health plan administrator and obtain all pertinent financial information concerning coverage and payments under my policy. I direct the insurance company or health plan administrator to release such information to Camelback Spine Care. I authorize Camelback Spine Care to release all medical information requested by my health insurance carrier, Medicare, other physicians or providers, and any other third-party payers.

10.RELEASE OF INFORMATION- I hereby authorize the and direct Camelback Spine Care to release to governmental agencies, insurance carriers, or others who are financially liable for such professional and medical care, all information needed to substantiate claim and payment.

I have read and understand the practice's financial policy of Camelback Spine Care and I agree to be bound by its terms. I understand that I am financially responsible for ALL services I receive from Camelback Spine Care. I hereby assign all medical and surgical benefits and authorize my insurance carrier (s) to issue payment directly to Camelback Spine Care. This financial policy is binding upon you, your estate, executors and/or administrators, if applicable.

I also understand and agree that such terms may be amended by the practice from time to time.

Authorized Parties

By signing below, I authorize Camelback Spine Care, its agents and employees ("Provider"), to use and / or disclose any and all of my protected health information of any kind and description to the following party or parties ("Recipients"):

Party Relationship

Authorization to Disclose Protected Health Information Including HIV & AIDS Related Information

I understand that neither Provider nor Recipient may condition treatment, payment, enrollment or eligibility for benefits on whether I sign this Authorization. In addition, I understand that Recipient may re-disclose the Records and that the Records may no longer be protected by the Federal privacy regulations.

I acknowledge and agree that the protected health information authorized to be disclosed under this Authorization may include records for drug or alcohol abuse or psychiatric illness, and records of testing, diagnosis or treatment for HIV, HIV- related diseases and communicable disease-related information.

With respect to any communicable disease-related information protected by State confidentiality rules and disclosed under this Authorization, Recipient is prohibited from making any further disclosure of this information unless further disclosure is expressly permitted by me pursuant to a separate written authorization or is otherwise permitted by applicable law.

Further, with respect to any drug and alcohol abuse treatment information disclosed under this Authorization, this information has been disclosed from records protected by Federal confidentiality rules (42 C.F.R. Part 2). The Federal rules prohibit the recipient of this information from making any further disclosure of this information unless further disclosure is expressly permitted by me pursuant to a separate written authorization or is otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

Authorized Parties

I acknowledge that I have had the opportunity to review Camelback Spine Care Notice of Privacy Practices and Patient Rights and Responsibility, which is displayed for public inspection at its facility and on its website. These Notices describe how my protected health information and rights may be used and disclosed, and how I may access my health records.

I understand I have the right to refuse to sign this authorization and that I do not have to sign this authorization to receive treatment at Camelback Spine Care. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the Federal Health Insurance Portability and Accountability Act (HIPAA). I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the privacy officer whose address is listed below:

Privacy Officer Camelback Spine Care
13760 N 93rd Ave #203 Peoria,
AZ 85381

Expiration

This Authorization will remain effective until the expiration date specified below or, if no date is set forth below, for one-year following the date of this signing, at which time this Authorization will expire. A photocopy of this Authorization will be considered effective and valid as the original.

Signature

Authorization to Disclose Health Information to Camelback Spine Care

or its agent(s) to disclose my health information as described in this authorization to:

Camelback Spine Care 13760 N
93rd Ave #203 Peoria, AZ 85381
Office: 602.714.6970
Fax : 602.714.5176

I understand I may revoke this Authorization at any time by sending written notice of my revocation to Camelback Spine Care health information management department. I understand that my revocation will not be effective to the extent the healthcare provider has taken action in reliance on this Authorization. Unless revoked sooner, this Authorization will expire on the following date, event, or condition. If no date, event, or condition is written, this authorization will expire 1 year from the date signed.

A photocopy of this Authorization will expire 1 year from the date signed. A photocopy of this Authorization will be considered effective and valid as the original.

I understand that the health information authorized to be disclosed under this Authorization may include information regarding drug or alcohol abuse or psychiatric illness, and records of testing, diagnosis or treatment for HIV, HIV-related diseases and communicable disease-related information.

I understand that Camelback Spine Care may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization. I understand that the Recipient may redisclose the records and that the records may no longer be protected by Federal privacy regulations.

I have read this Authorization and I acknowledge that I am familiar with and fully understand its terms and conditions.