patient intake form · release of records i give permission to the pain institute, to obtain copies...

1

PATIENT INFORMATION

Date

Name DOB

Address Age Sex

City State ZIP

Home Phone Cell Phone

E-mail Address

Secondary Notification

Name Relationship Phone

Primary Care Physician Name

Primary Care Physician Phone

Referring Physician Name

Referring Physician Phone

SOCIAL HISTORY

Please provide complete answers to the following questions

Marital Status: ❏ Married ❏ Single ❏ Widowed ❏ Divorced

Race: Primary Language Spoken ❏ English ❏ Other:

Ethnicity ❏ Hispanic/Latino ❏ Non-Hispanic/Latino ❏ Other (please specify)

Do you smoke? ❏ Current ❏ Former ❏ Never If yes, how much?

Do you drink alcoholic beverages? ❏ Yes ❏ No If yes, how much?

Have you received treatment for any type of addiction? ❏ Yes ❏ No If yes, describe:

Has any immediate family member ever received treatment for any type of addiction? ❏ Yes ❏ No If yes, describe:

Are you pregnant or plan to become pregnant? ❏ Yes ❏ No

Name of employer

Occupation. What work do you do? What does your work involve?

How many hours do you work per week?

How much work, if any, have you missed in the past month due to pain?

PIF 1017

PATIENT INTAKE FORM

252 Whittington Parkway • Louisville, KY 40222-4904 • Phone 502-423-7246 • Fax 502-426-7247

2

Printed Name DOB

PAIN HISTORY

Describe in your own words what your pain is like (where it is, how it feels, is it constant, does it come and go, etc.)

How long have you had this problem?

What is the cause of the pain, if known?

PREVIOUS TREATMENT FOR PAIN

HELPFUL

PLEASE CHECK ONE: YES NO YES NO

Epidural/Other Pain Injections Physician Date

Medication Management Physician Date

Surgery Surgeon Date

Physical Therapy For What Area of Body:

Therapist Date

Tens Unit Comments Date

Psychologist/Psychiatrist Therapist Date

Chiropractor Therapist Date

Which of the following tests have you had to evaluate your pain? Please list the approximate date of test, the name of the facility where the test was performed and the name of the ordering physician

TEST DATE FACILITY ORDERING PHYSICIAN

X-Ray

CT Scan

MRI

EMG

Myelogram

Bone Scan

DNA Testing

MEDICAL HISTORY

Height Weight

CHECK ANY OF THE FOLLOWING CONDITIONS YOU HAVE HAD OR PRESENTLY HAVE

❏ Diabetes ❏ Type 1 ❏ Type 2 ❏ Bleeding Disorder ❏ Emphysema ❏ Fibromyalgia ❏ Ulcer/Gastric Bleeding

❏ Cancer Type: ❏ Kidney Problems Type:

❏ Heart Problems: ❏ Chest Pain ❏ Heart Attack ❏ Valve Problem ❏ Rhythm Problem ❏ Arthritis ❏ Asthma

❏ Psychological Disorders: ❏ Depression ❏ Bipolar ❏ Anxiety ❏ ADD ❏ PTSD ❏ High Blood Pressure

Explain above answers as needed:

LIST ALL SURGERIES YOU HAVE HAD

SURGERY DATE SURGERY DATE

PIF 1014


3

Printed Name DOB

PLEASE LIST ANY ALLERGIES ALONG WITH THE REACTION. THIS INCLUDES DRUG, FOOD AND PRODUCT ALLERGIES

ALLERGY REACTION

Are you allergic to latex products? ❏ Yes ❏ No Reaction:

Are you taking any blood thinning medications? ❏ Yes ❏ No If yes, please list:

PLEASE LIST ALL PRESCRIPTION AND OVER-THE-COUNTER MEDICATIONS YOU ARE CURRENTLY TAKING. USE ADDITIONAL PAPER IF NEEDED.

MEDICATION WHY PRESCRIBED STRENGTH (MG) EFFECTIVENESS

PLEASE LIST MEDICATIONS YOU HAVE TRIALED BUT ARE NO LONGER TAKING (CHECK ALL THAT APPLY): ❏ NONE

Pharmacy Name Phone

Pharmacy Address

Have you received a pneumonia vaccine? ❏ Yes ❏ No Date:

❏ Aleve

❏ Ambien

❏ Aspirin

❏ Avinza

❏ Baclofen

❏ Celebrex

❏ Clonazepam

❏ Clonidine

❏ Codeine

❏ Cymbalta

❏ Darvocet

❏ Dilaudid

❏ Duragesic

❏ Effexor

❏ Elavil

❏ Embeda

❏ Flexeril

❏ Hydrocodone

❏ Kadian

❏ Lidoderm

❏ Lortab

❏ Lunesta

❏ Lyrica

❏ Methadone

❏ Mexilitine

❏ Mobic

❏ Morphine

❏ Naproxyn

❏ Neurontin

❏ Nortriptyline

❏ Nucynta

❏ Opana

❏ Oxycontin

❏ Oxyfast

❏ Paxil

❏ Percocet

❏ Prednisone

❏ Prozac

❏ Relafen

❏ Remeron

❏ Robaxin

❏ Soma

❏ Savella

❏ Skelaxin

❏ Stadol Nose Spray

❏ Talwin

❏ Tegretol

❏ Topamax

❏ Tylenol

❏ Ultram

❏ Valium

❏ Zanafle

❏ Zoloft

PIF 1014

LITIGATION

If your pain is due to an accident, is litigation (legal suit) or an insurance settlement pending? Do you have plans to pursue legal or insurance settlement in the future? If yes to either question, please describe:

RELEASE OF RECORDS

I give permission to The Pain Institute, to obtain copies of records, diagnostic procedures, etc., from previous treating physicians and facilities that may benefit in the understanding and t eatment of my current pain condition.

Name Date


4PIF 1017

Printed Name DOB

FAMILY HISTORY

Please place an “X” in the box under family member, if it applies. ❏ I am adopted

MOTHER FATHER SISTER BROTHER

Unknown

Alcoholism

Anemia

Arthritis

Anesthetic Complications

Anxiety

Asthma

Birth Defects

Bleeding Disease

Breast Cancer

Colon Cancer

Depression

Diabetes

Heart Disease

Hypertension

High Cholesterol

Kidney Disease

Lung/Respiratory Disease

Migraines

Osteoporosis

Seizures

Severe Allergies

Stroke

Thyroid Problems

Other Cancer

Angina

Cervical Cancer

Congestive Heart Disease Male Younger than 55

Congestive Heart Disease Female Younger than 65

Growth/Development Problem

Headaches

Lung Cancer

Melanoma

Ovarian Cancer

Psychiatric Care

Uterine Cancer

Weight Disorder

Other Medical Problems

PMS

Endometriosis


5

Printed Name DOB

PLEASE RATE YOUR PAIN

0 = NO PAIN 5 = DISTRESSING PAIN 10 = UNBEARABLE PAIN

GOOD DAY 1 2 3 4 5 6 7 8 9

BAD DAY

CURRENT

PIF 1017

ON THE DRAWINGS BELOW, PLEASE CHECK THE BOX NEXT TO THE AREA WHERE YOU FEEL PAIN

PAIN CERTIFICATION

I certify that I have truthfully completed all sections of the Patient Intake Form and have not knowingly withheld any information concerning my medical history, past or present.

Due to potential adverse effects of the procedures or medications on the status of my fertility or pregnancy, I will inform a healthcare provider of The Pain Institute if there is any change in my reproductive status.

Name Date

R L R L L R

R L

0 10

1 2 3 4 5 6 7 8 90 10

1 2 3 4 5 6 7 8 90 10


I hereby authorize and assign payment made directly to M.C. Cronen & Associates, Inc., P.S.C. of the covered insurance benefits, including major medical benefits, whether payable to me by Blue Cross/ Blue Shield, Medicare, Workers’ Compensation, and/or commercial insurance companies. I understand that my health insurance provider may not cover part or all of the medical services rendered, and I fully understand that I am financially responsible for and agree to pay all charges not paid by my health care coverage, including deductibles, coinsurance, and payments from insurance companies sent directly to me.

This assignment shall apply to all medical services now rendered and to be rendered in the future until this authorization and assignment is revoked.

If prior authorization or certification for medical services is required under my health care coverage, I agree to obtain and furnish such authorization or certification.

I authorize the release of medical information as may be required to process the claims for payment of the medical services rendered, and it is expressly understood that the right of such information to be privileged is hereby waived.

I agree to promptly notify your office of any change of address.

A copy of this assignment shall be considered as valid as the original.

ASSIGNMENT OF INSURANCE BENEFITS AND STATEMENT OF SERVICE


X ______________________________________________________________________________ _________________________Signature of Patient (or Guardian) Date

X ______________________________________________________________________________ _________________________Signature of Subscriber Date

I consent to the use or disclosure of my protected health information by M.C. Cronen & Associates Inc., P.S.C. for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of M.C. Cronen & Associates Inc., P.S.C.

I understand that diagnosis or treatment of me by The Pain Institute may be conditioned upon my consent as evidenced by my signature on this document.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations of the practice. The Pain Institute is not required to agree to the restrictions that I may request. However, if M.C. Cronen & Associates Inc., P.S.C. agrees to a restriction that I request, the restriction is binding on M.C. Cronen & Associates Inc., P.S.C. and The Pain Institute.

I have the right to revoke this consent, in writing, at any time, except to the extent that The Pain Institute or M.C. Cronen & Associates Inc., P.S.C. has taken action in reliance on this consent.

My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review M.C. Cronen & Associates Inc., P.S.C.’s Notice of Privacy Practices prior to signing this document.

The M.C. Cronen & Associates Inc., P.S.C.’s Notice of Privacy Practices has been provided to me.

The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations at The Pain Institute.

The Notice of Privacy Practices for The Pain Institute is also provided at 252 Whittington Parkway, Louisville, KY 40222 and on The Pain Institute web-site.

This Notice of Privacy Practices also describes my rights and the duties of The Pain Institute with respect to my protected health information.

M.C. Cronen & Associates Inc., P.S.C. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.

I may obtain a revised notice of privacy practices by accessing The Pain Institute’s web site, calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.

X ______________________________________________________________________________ _________________________ Signature of Patient or Personal Representative Date

X _____________________________________________________________________ __________________________________ Printed Name of Patient or Personal Representative Description of Personal Representative’s Authority

CONSENT FOR PURPOSES OF TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS


The Pain Institute would like for our referring offices t o k now t hat t he f ollowing insurances require a referral from the patient’s PCP and a MRI report of the area of pain within the last six months before they can be referred to pain management. These insurances also require at least six weeks of physical therapy before injections can be authorized. If the physical therapy has not yet been ordered our physicians will order at the time of consultation.

PASSPORT (Referral comes from Passport’s website initiated by PCP)

INDIANA MEDICAID PLANS (MHS-referral comes from MHS’s website initiated by PCP,

MDWISE, ANTHEM, HHP, HIP, HHW, HOOSIER CARE CONNECT)

HUMANA CARESOURCE MEDICAID

CIGNA – NO REFERRAL NEEDED

AETNA BETTER HEALTH

WELLCARE MEDICARE

A referral, physical therapy note if available, and the MRI report need to be faxed to New Patient Scheduling at 502-429-5913, before the appointment can be made. Thanks for your assistance and call if any questions: 502-292-5566.


patient intake form · release of records i give permission to the pain institute, to obtain copies...

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