New Patient Registration

David S. Groopman, M.D., FAAMA

4118 E. Parham Road

Richmond, Virginia23228

(804) 755-7800

New Patient Registration

Name______Sex (circle one) Male Female

Street Address ______

City, State, Zip______Home Phone ( )______

Date of Birth ____/_____/_____ Age ______Marital Status (circle one) Single Married Divorced

Widowed Separated

Employer ______Occupation ______

Work Phone ( ) ______Referred By ______

Emergency Contact (Name and Phone #) ______

For Women Only: Are You Pregnant? Yes No

For All Patients:

Have you had acupuncture before? Yes No Chinese herbal medicine? Yes No

What is the reason for today’s visit? ______

How long have you had this condition? ______Initial cause? ______

Does it bother your: Sleep Work Other (What?) ______Is it getting worse? Yes No

What makes it better? ______What makes it worse? ______

Are you under the care of a physician now? Yes No If yes, for what condition? ______

Who is your physician? ______Physician phone # ______

Rev. 09/01/08

David S. Groopman, M.D., FAAMA

Acupuncture Informed Consent to Treat

I, ______, being ______years of age and residing at ______, do hereby voluntarily consent to be treated with acupuncture administered by David S. Groopman, M.D.

Acupuncture is performed by the insertion of very thin needles through the skin, and/or by application of heat on or near the surface of the body, and/or by suction cups applied to the skin. Once inserted, the needles may be stimulated manually or electrically, and/or may have certain Chinese medicine herbs burned on or near them.

I have been informed and understand that acupuncture is a generally safe method of treatment, but certain adverse side effects, while infrequent, may result. These could include but are not limited to local bruising, minor bleeding, numbness or tingling near the needling sites, temporary pain or discomfort and dizziness, nausea or fainting. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax), and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that there is a risk of burning/scarring from moxibustion (heating of needles with herbs) and/or cupping. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.

I have been informed and understand that Dr. Groopman does not practice primary care medicine and does not offer any services other than acupuncture and treatment modalities directly relating to the practice of acupuncture.

I have been informed and understand that Dr. Groopman does not diagnose medical conditions.

I have been informed and understand that I will need to consult with another healthcare provider if I seek a diagnosis for my condition(s) or if I seek services other than acupuncture.

I have been given no guarantees regarding the use and/or effectiveness of acupuncture and know that I am free to stop treatment any time.

By voluntarily signing below, I show that I have carefully read and understand the above consent to treatment, have been advised about the risks of acupuncture and related procedures. I intend this consent to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment.

Signature of Patient or Guardian: ______Date: ______

Rev. 09/10/2009

David S. Groopman, M.D., FAAMA

Fees and Payment Policy

Dr. Groopman does not participate with any insurance carrier. Our office does not file insurance claims.

WE DO NOT ACCEPT DEBIT/CREDIT CARDS. WE DO ACCEPT CASH AND CHECKS.

PAYMENT IN FULL IS DUE AT THE TIME OF SERVICE.

New Patient - Initial Visit

Includes Chinese Medicine Assessment and Acupuncture Treatment $ 250.00

Established Patient – Acupuncture Treatment $145.00

Scar Deactivation / Injection $ 75.00

Broken Appointment / Late Cancellation Policy:

You may be charged the full visit amount for broken appointments or cancellations without 24 hours advance notice.

I understand that I am responsible for full payment of all services at the time they are rendered. I have read and understand the broken appointment/late cancellation policy.

Signature: ______Date:______

ATTENTION MEDICARE BENEFICIARIES

MEDICARE DOES NOT COVER ACUPUNCTURE. DR. GROOPMAN HAS OPTED OUT OF THE MEDICARE PROGRAM. WHEN A PHYSICIAN OPTSOUT OF MEDICARE, MEDICARE REQUIRES A PRIVATE CONTRACT BE SIGNED BY BOTH PHYSICIAN AND PATIENT PRIOR TO SERVICES BEING RENDERED. CARFULLY READ, SIGN AND DATE THE ATTACHED PRIVATE CONTRACT. PLEASE LET US KNOW IF YOU HAVE ANY QUESTIONS.

Revised 06/05/2013

COMPLETE ONLY IF YOU ARE A MEDICARE BENEFICIARY. OTHERWISE LEAVE BLANK.

MEDICARE BENEFICIARY PRIVATE CONTRACT FOR MEDICAL SERVICES

Dr. Groopman has chosen to opt out of the Medicare program. When a physician optsout of Medicare, Medicare requires the following private contract be signed by both physician and patient prior to services being rendered. Optout status is effective for a period of 2 years and can be renewed/continued. A new contract must be signed for each optout period.

Please read carefully, sign and date.

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This contract is entered into by and between:

David S. Groopman, M.D. (physician) Patient Name: ______

4118 E. Parham Road and Address: ______

Richmond, Virginia23228 City,State,Zip: ______

I understand that David S. Groopman, M.D. has opted out of the Medicare program. The current optout period begins

April 1, 2014and expires on March 31, 2016. I understand that Dr. Groopman has the option to renew the optout status

every 2 years. I understand I will be required to sign a private contract each time Dr. Groopman renews his optout status.

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Physician Obligations

The physician acknowledges:

He is not excluded from Medicare under sections 1128, 1156, 1892 or any other section of the Social Security Act.
This contract shall not be entered into with the beneficiary or the beneficiary’s legal representative during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. (405.440).
He must retain this contract with original signatures of both parties to this contract for the duration of the opt-out period, and it shall be made available to the Centers for Medicare and Medicaid Services (CMS) upon request.
That he must enter into a contract for each opt-out period.

The physician shall provide a copy of this contract to the beneficiary, or to his legal representative, before items or services have been furnished to the beneficiary under the terms of this contract.

Patient/Beneficiary Obligations

The beneficiary or his or her legal representative:

Agrees not to submit a claim, nor ask the physician to submit a claim, for any items or services furnished by physician.
Accepts full responsibility for payment of the physician’s charge for all services furnished by the physician.
Understands that no payment will be provided by Medicare for items or services furnished by the physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
Understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician.
Has entered into this contract with the knowledge that he or she has the right to obtain Medicare covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for covered services, and that the beneficiary has not been compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners who have not opted-out.
Understands that Medigap plans do not, and other supplemental plans may elect not to, make payment for items and services not paid for by Medicare.
Acknowledges that this agreement is not being entered into with the physician at a time when the patient/beneficiary requires emergency care services or urgent care services.
Acknowledges that a copy of this contract has been provided to the beneficiary, or to his or her legal representative, before services have been rendered to the beneficiary under the terms of this contract.

The beneficiary acknowledges that this written private contract contains sufficiently large print to ensure that the beneficiary is able to read this contract.

Physician Signature: ______Patient Signature: ______

Printed: David S. Groopman, M.D.

Date: ______Date: ______

Medical History Questionnaire
Family Medical History
___ / Allergies (list): ______
___ / Arteriosclerosis
___ / Asthma
___ / Alcoholism
___ / Cancer (list): ______
___ / Diabetes
___ / Heart Disease
___ / High Blood Pressure
___ / Seizures
___ / Stroke
Your Past Medical History
Check any of the following conditions you currently have or have had in the past.
___ / AIDs/HIV / ___ / Mumps
___ / Alcoholism / ___ / Pacemaker
___ / Allergies / ___ / Pleurisy
___ / Appendicitis / ___ / Pneumonia
___ / Arteriosclerosis / ___ / Polio
___ / Asthma / ___ / Rheumatic Fever
___ / Birth Trauma (your birth) / ___ / Scarlet Fever
___ / Cancer / ___ / Seizures
___ / Chicken Pox / ___ / Stroke
___ / Diabetes / ___ / Surgery (list): ______
___ / Emphysema / ___ / Thyroid Disorders
___ / Epilepsy / ___ / Major Trauma (list car accidents, falls, etc. ______
___ / Goiter / ______
___ / Gout / ___ / Tuberculosis
___ / Heart Disease / ___ / Typhoid Fever
___ / Hepatitis / ___ / Ulcers
___ / Herpes / ___ / Venereal Disease
___ / High Blood Pressure / ___ / Whooping Cough
___ / Measles / ___ / Other (list): ______
___ / Multiple Sclerosis / ______
Your Diet
Appetite (circle one) High Low / Average Daily Menu
___ Coffee (cups per day) / Morning / ______
___ / Soft Drinks (per day) / Snack / ______
___ / Artificial Sweetener / Noon / ______
___ / Sugar / Snack / ______
___ / Salty Food / Evening / ______
___ / Water (per day) / Snack / ______
Medications/Vitamins/Supplements
List all taken within the last 2 months: ______
______
______
Your Lifestyle
___ / Alcohol (per week) ______
___ / Tobacco (per week) ______
___ / Marijuana
___ / Drugs
___ / Stress
___ / Occupational Hazards
___ / Regular Exercise (list type and frequency) ______
______
General Symptoms
___ / Poor appetite / ___ / Cold hands or feet
___ / Heavy appetite / ___ / Poor circulation
___ / Strongly like cold drinks / ___ / Shortness of breath
___ / Strongly like hot drinks / ___ / Fever
___ / Recent weight loss/gain / ___ / Chills
___ / Poor sleep / ___ / Night sweats
___ / Heavy sleep / ___ / Sweat easily
___ / Dream disturbed sleep / ___ / Muscle cramps
___ / Fatigue / ___ / Vertigo or dizziness
___ / Lack of strength / ___ / Bleed or bruise easily
___ / Bodily heaviness / ___ / Peculiar taste (describe): ______
Head, Eyes, Ears, Nose, Throat
___ / Glasses / ___ / Excessive phlegm (color): ______
___ / Eye strain / ___ / Recurrent sore throat
___ / Eye pain / ___ / Swollen glands
___ / Red eyes / ___ / Lumps in throat
___ / Itchy eyes / ___ / Enlarged thyroid
___ / Spots in eyes / ___ / Nose bleeds
___ / Poor vision / ___ / Ringing in ears
___ / Blurred vision / ___ / Poor hearing
___ / Night blindness / ___ / Earaches
___ / Glaucoma / ___ / Headaches
___ / Cataracts / ___ / Dry mouth
___ / Teeth problems / ___ / Excessive saliva
___ / Grinding teeth / ___ / Sinus problems
___ / TMJ / ___ / Migraines
___ / Facial pain / ___ / Concussion
___ / Gum problems / ___ / Other head/neck problems ______
___ / Sores on lips/tongue / ______
Respiratory
___ / Difficulty breathing when lying down
___ / Shortness of breath
___ / Tight chest
___ / Asthma/wheezing
___ / Cough Wet or Dry? ______Thick or Thin? ______Color of phlegm? ______
___ / Coughing Blood
___ / Pneumonia
Cardiovascular
___ / High blood pressure / ___ / Difficulty breathing
___ / Blood clots / ___ / Tachycardia
___ / Low blood pressure / ___ / Heart palpitations
___ / Fainting / ___ / Phlebitis
___ / Chest pain / ___ / Irregular heartbeat
Gastrointestinal
___ / Nausea / ___ / Intestinal pain/cramping
___ / Vomiting / ___ / Itchy anus
___ / Acid regurgitation / ___ / Burning anus
___ / Gas / ___ / Rectal pain
___ / Hiccup / ___ / Hemorrhoid
___ / Bloating / ___ / Anal fissures
___ / Bad breath
___ / Diarrhea / Bowel movements: Frequency ______
___ / Constipation / Color / ______
___ / Laxative use / Texture/form ______
___ / Black stools / Odor / ______
___ / Bloody stools
___ / Mucous in stools
Musculoskeletal
___ / Neck/shoulder pain / ___ / Rib pain
___ / Muscle pain / ___ / Limited range of motion
___ / Upper back pain / ___ / Limited use
___ / Lower back pain / ___ / Other ______
___ / Joint pain
Skin and Hair
___ / Rashes / ___ / Itching
___ / Hives / ___ / Hair loss
___ / Eczema / ___ / Change in hair/skin texture
___ / Psoriasis / ___ / Fungal infections
___ / Acne / ___ / Other hair/skin problems ______
___ / Dandruff
Neuropsychological
___ / Seizures / ___ / Irritability
___ / Numbness / ___ / Easily stressed
___ / Tics / ___ / Abuse survivor
___ / Poor memory / ___ / Considered/attempted suicide
___ / Depression / ___ / Seeing a therapist
___ / Anxiety / ___ / Other ______
Genito-urinary
___ / Pain on urination / ___ / Wake to urinate
___ / Frequent urination / ___ / Increased libido
___ / Urgent urination / ___ / Decreased libido
___ / Blood in urine / ___ / Kidney stone
___ / Unable to hold urine / ___ / Impotence
___ / Incomplete urination / ___ / Premature ejaculation
___ / Venereal disease / ___ / Nocturnal emission
___ / Bedwetting
Gynecology
Age menses began ______/ Length of cycle (day 1 to day 1) ______Duration of flow ______
___ / Irregular periods
___ / Painful periods
___ / PMS
___ / Vaginal discharge (color) ______
___ / Vaginal sores
___ / Vaginal odor
___ / Clots
___ / Breast lumps
___ / Breast Implants
Number of pregnancies _____ / Number of Live Births _____ Number of premature births ______
Age at Menopause ______/ Date of last PAP ______Start date of last period ______
Other:
______
______
______
______

David S. Groopman, M.D., FAAMA

4118 E. Parham Road

Richmond, Virginia23228

Medical Information Disclosure Authorization

I authorize David S. Groopman, M.D. to discuss and disclose any/all information regarding my medical condition(s) and medical care to the following person(s):

Name: ______Relationship to Patient: ______

Patient Name (PLEASE PRINT):______

Signature of Patient/Guardian: ______Date: ______

HIPAA Privacy Practice Written Acknowledgement

Notice of Privacy Practices Written Acknowledgement Form

Our Notice of Privacy Practices provides information about how we may use and disclose medical information about you. As provided in our notice, the terms of our notice may change in accordance with Federal regulations.

A current paper copy will be provided at your request.

I acknowledge I have been provided a copy of the Notice of Privacy Practices for David S. Groopman, M.D., FAAMA.

Patient Name (PLEASE PRINT):______

Signature of Patient/Guardian: ______Date: ______