Registration & Confidential Medical HistoryNEWPORTHANDCENTER
Name ______Date of Birth _____/_____/_____ SS# ______
Last First MI
Address ______Home Phone ______
Street Address City Zip
Cell Phone ______
Male Female Single Married OtherEmployer ______
Student? Yes No School ______Email ______Referring Physician ______
Emergency Contact ______ Spouse Parent/Child Other
Name Phone Relationship
Specify diagnosis and/or body part we will be treating: ______
Is this injury work-related? Yes No Auto Accident? Yes No Other Accident? Yes No
Is there any legal action filed, or will there by any legal action filed regarding this injury? Yes No
Date of Injury or Onset of Symptoms _____/______/____ Date of Surgery _____/_____/_____
Are you currently taking 1. Pain Medication Yes No 2. Anti-Inflammatory Yes No 3. Anti-Coagulant/Blood thinner Yes No
List any surgeries: ______
Have you had Diagnostic or Rehabilitative Services for this Injury? MRI Xrays Other: ______
Have you had any Occupational/Physical/Home Therapy or any Chiropractic visits this year? Specify which: ______
Do you have or have you had any of the following?
YES / NO / YES / NOAsthma, Bronchitis or Emphysema / Arthritis/Swollen Joints
Coronary Heart Disease / Osteoporosis
Pacemaker / Emotional/Psychological Problems
High Blood Pressure / Severe/Frequent Headaches
Stroke/ TIA / Vision/Hearing Difficulty
Blood Clot/Embolism/ DVT / Dizziness
Epilepsy/Seizures / Are you Pregnant?
Infection in past 3 months / Allergies
Infectious disease / Other Medical Condition
Diabetes / Smoking
Cancer or Chemo/Radiation / Alcohol Consumption / Daily ______
Are you aware of your diagnosis? Yes No Are you aware of your Prognosis? Yes No
I hereby agree and give my consent to medical treatment in treating my physical condition. I authorize release of any medical information needed to process my claim. I understand that I am responsible for any charges that are not covered by my insurance carrier. Furthermore, I understand that I am responsible to inform the office of any changes that occur. I authorize release of payment directly to NHC, regardless of participation in or out-of-network. Should I default on my financial responsibility and collection action is necessary, I will be responsible for collection costs that are incurred.
Patient/Parent/Guardian Signature: ______Date: ______
I acknowledge that I have seen the “Notice of Privacy Practices”. I understand that I may ask questions about this at any time.
Patient/Parent/Guardian Signature: ______Date: ______
Mydocs/forms/Patient Registration 2012 Revised
NewportHandCenter
360 San Miguel Drive▪ Suite 302 ▪ Newport Beach, Ca 92660
Phone 949-644-6050 ▪ Fax 949-644-4427
RELEASE OF MEDICAL RECORDS
Name of Patient:______Date of Birth:______
I hereby request release of my medical records (or my child’s medical records) to NewportHandCenter. Included in this release would be any records pertaining to the diagnosis for which Newport Hand Center is treating, or will be treating me (or child).
I also hereby authorize release of my medical records (or my child’s medical records) pertaining to treatment at NewportHandCenter to
√the referring physician, attending surgeon(s) and other treating physicians
√the insurance company being billed for these services and any representative or
agent of my insurance plan
Other (if specified) ______
A photocopy or fax of this document with my signature shall be considered as a valid release and shall be in effect until revoked.
I understand I can revoke this authorization at any time in writing to NewportHandCenter, but that revoking this authorization will not affect disclosures made before the revocation is received.
______
SignedDate
______
Relationship if not patient
PLEASE NOTE: For Disclosure on Liens or any Attorney related requests, there is a separate form for Release of Medical Records . Please refer to form entitled HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508
Documents/forms/newpt/releasemedical
NewportHandCenter
360 San Miguel Drive▪ Suite 302 ▪ Newport Beach, Ca 92660
Phone 949-644-6050 ▪ Fax 949-644-4427
CANCELLATION POLICY
To Our Patients:
NewportHandCentertries to schedule each patient at a time convenient for them and makes every effort to see each patient at their scheduled appointment time. Our goal is to accommodate every patient and to make sure we have enough time with our patients to provide the best occupational therapy available.
To be able to do this, we refrain from double booking patients, which most offices do to allow for cancellations and no shows.
For this reason, we require at least 24 hours advance notice if you are unable to attend your scheduled appointment.
Any same day cancellations or no-shows will be billed at $35 per occurrence.
We will excuse one emergency, but to be fair to all, there will be no exceptions after the first unplanned schedule change.
Thank you.
My signature below indicates that I have read and understand the above statements.
Print Name______
Signature______Date ______