This acknowledgement of notice and consent authorizes ALL-PRO ORTHOPEDICS AND SPORTS MEDICINE P.A. to use health information about you for treatment, payment, and health care operations perposes.
NOTICE OF PRIVACY PRACTICES: ALL-PRO ORTHOPEDICS AND SPORTS MEDICINE P.A. has a Notice of Privacy Practices which describes how we may use your protected health information and how you can access your protected health information and exercise other rights concerning your protected health information. You may review our current notice prior to signing this acknowledgement and consent.
AMENDMENTS: We reserve the right to change our Notice of Privacy Practices and to make the terms of any change effective for all protected health information that we maintain, including information created or obtained prior to the date of the effective date of the change. You may abtain a revised notice by submittings a written request to our Privacy Officer.
I have received the Notice of Privacy Practices for ALL-PRO ORTHOPEDICS AND SPORTS MEDI P.A..
They are authorized to use health information about (please print patient's name)
for treatment, payment, and healthcare operations purposes consident with its Notice of Privacy Practices.
Personal representative information (if applicable)
Identity of Recipents: Provide the name or other specific indentification of the person(s) or class of persons to whom the covered entity may disclose the covered information:
Do hereby IRREVOCABLY ASSIGN to the above-named medical provider, any right or benefits under my policy of insurance with
, for any service and/or charges provided by the above medical provider. Pursuant to this ASSIGNMENT OF BENEFITS, you are hereby directed to mail any and all checks directly and solely payable to the above named medical provider at the address listed on the HCFA-1500A form in box 33. As part of this ASSIGNMENT OF BENEFITS, I hereby instruct the insurance carrier that in the event the medical benefits are disputs for any reason, including medical reasonableness and/or necessity, that the amount of benefits claimed by ALL-PRO ORTHOPEDICS AND SPORTS MEDICINE PA is to be set aside and not disbursed until the dispute is resolved.
The undersigned paitent ("Patient") authorizes All-Pro Orthopedics ans Sports Medicine P.A. ("The Provider") to furnish the undersigned attorney ("Attorney") a full report of examination, diagnosis, treatment, operation and/or prognosis, as filed by the Patient\'s doctor with respect to health care services and procedures that Patient received or may be receiving the furture with Provider (in the aggregate, "Services") and Provider\'s bill for services ("the Bill") as related to injury(s) that the Patient sustained as the result of an accident that occurred on
(date of accident) (the "Accident"). With respect to the Provider providing such services to Patient:
1. Is your problem the result of an injury or accident
2. Are you represented by an attorney
3. Have you had a problem like this before?
4. Have you been seen in an ER?
5. Race the pain (10 being the most pain):
6. Do the symptoms wake you from sleep?
7. Please describe the symptoms:
8. What is the timing of the symptoms?
9. Is the problem getting better or worse?
10. What makes the symptoms worse?
11. Are there any other symptoms associated with this problem?
How you had any prior tests?
How you had any prior treatment for this problem?
Type of treatment
Status of symptoms after treatment (select only those that apply)
Date of treatment
Select all previous Hospitalizationa/surgeries: None
Other Orthopedic Surgery
Mark all that currently apply:
Are you talking blood thinners:
Have any direct relatives had any of the following disorders? None for all
Do you use tobacco?
Do you drink alcohol?
Are you currently working?
If no, what date did you last work?
Please list work restriction, if any:
Do you have any allergies?
If Yes, Please list below:
Medication, Relevant Food, or "Seasonal"
Please list all medications you take on a regular basis:
Dosage and Frequency (e.g. 20 mg, once/day)
Do you have a personal history of any of the following?
Please list any other conditions or details of conditions marked above:
April 28th, 2019
April 9th, 2019
March 22nd, 2019