New Patient PacketShare Step 1 of 10 10% Name(Required) First Middle Last Date of Birth(Required) MM slash DD slash YYYY Sex(Required)MaleFemaleHiddenGender (OLD version)MaleFemaleOtherSocial Security Country(Required)-- Enter country --AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte dIvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwePrimary Residence (non-US)(Required) Street Address City State / Province / Region ZIP / Postal Code Primary Residence(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneHiddenHome PhoneCell Phone(Required)Work PhoneUSA Phone Number (if any)Local Phone (Your Country #)(Required)E-mail Address(Required) How did you first learn about Dr. Badia?(Required)- Select One -Family or FriendsSearch Engine (i.e. Google, Yahoo, etc.)Social Media- Facebook- Twitter- Google +- OtherTV/RadioMagazine/NewspaperOther (Please specify below)Other: About Your Insurance:(Required)Workers' compensation caseAutomobile accident caseOther insuranceWorkers Comp or Auto InsuranceCompany Name Address for claims Street Address City State / Province / Region ZIP / Postal Code Adjuster Name PhonePhonePhonePrimary InsuranceCompany Name PhonePhonePolicy number Group number Policy holder name Date of birth MM slash DD slash YYYY Social security number Relationship to patient Do You Have a Secondary Insurance?YesNoSecondary InsuranceCompany Name PhonePhonePhonePolicy number Group number Policy holder name Date of birth MM slash DD slash YYYY Social security number Relationship to patient Primary Care PhysicianPhysician Name PhonePhoneEmergency ContactContact Name Relationship PhonePhoneAddress Do you have an Advance Directive? (living will, health care surrogate)YesNoI do hearby consent to any medical care which is deemed advisable or necessary by my healthcare provider and grant authority to Badia Hand to Shoulder Center, to administer and perform all examinations, treatments, diagnostic procedures and surgeries needed now or in the future. I guarantee payment for all services rendered. All medical benefits including major medical benefits, private insurance, and any other health plan, are assigned to Badia Hand to Shoulder Center. The signature below confirms all of the information provided herein is true and accurate. Photocopy of this consent is to be considered as valid as the original. This is an agreement between Badia Hand to Shoulder Center, as creditor, and the Patient/Debtor named on this formInsurance: Insurance is a contract between you and your insurance company. It is your responsibility to understand your insurance plan benefits. In order to file your claims, we require a legible copy of the front & back of the insurance card, photo ID, social security number and verification of benefits by your insurance company prior to visits. It is the responsibility of the insured/patient to supply current and accurate information including primary and secondary insurance for claims submissions PRIOR to receiving services. All copay, coinsurance and deductibles are due at the time services are rendered.Failure to provide complete and accurate insurance information may result in the entire bill being your responsibility. Although we estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. Once the claim is processed, if there is any additional liability, you will be billed accordingly.Services unexpectedly denied by your insurance plan due to retroactive terminations, Coordination of Benefits (other health insurance that may be primary) denials, payment offset due to retroactive termination, failure to respond to your insurance plans with requested information or failure to provide our office with any new health insurance changes are all reasons patients may be responsible for payment of services received in our office. All of these circumstances are beyond our control. It is the patient’s responsibility to resolve any issues that arise with their eligibility and benefits.If you are covered by a plan that we are not participating providers for, payment is expected when services are rendered. We will provide you with an itemized receipt for you to file with your insurance. Your insurance company will be responsible for reimbursing you for any coverage you may have. We highly recommend you contact your insurance carrier and check your available benefits before care is received from our office. Do not assume that you will not owe anything, even if you have more than one insurance policy.Self-pay accounts: Self pay accounts are patients without insurance coverage, patients covered by insurance plans in which the office does not participate, or patients without an insurance card on file with us. It is always the patient’s responsibility to know if our office is participating with their plan. If you have health insurance and there is a discrepancy regarding your coverage or eligibility, the patient will be considered self-pay unless otherwise proven.Appointment Cancellation Policy: If you need to cancel your appointment, please notify our office within at least 24 business hours. Failure to do this keeps us from scheduling other patients that need to be seen. A fee will be charged for appointments not cancelled with 24 hours advanced notice. This includes cancelled appointments, rescheduled appointments, and missed appointments (no-shows). The fee for this is $50.00. This fee will have to be paid at the time of your rescheduled appointment; if no appointment is rescheduled, you will be billed for this fee. The provider will not see you until this fee has been paid.Collection fee: A fee totaling 30% of the balance due will be added to your account if we have to send your account to a collection agency. You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account to any credit reporting agency such as a credit bureau. Waiver of confidentiality: You understand that if this account is submitted to an attorney or collection agency, if we must litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.Returned checks: There is a fee currently of $25.00 for any checks returned by the bank. Payment made on a returned check must be made in cash or by a money order. This will be applied to your account in addition to the insufficient funds amount. You may be placed on a cash only basis following any returned check. Unsubstantiated credit card disputes will incur a $35.00 administrative fee.Disability forms, insurance forms, and other forms: There will be a fee of $75.00 for the completion of medical forms. Payment is due at the time the form is dropped off. Please allow 5-7 business days for these to be completed.Copying of records: There is a fee of $1/page for the first 25 pages and 25 cents for every page thereafter for copies of your records to be sent to another doctor or organization. You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history. Copies of images (x-ray, MRI) are available by CD and are subject to a $10.00 fee per disc.Responsible party (if not the patient) Acknowledgement of Privacy PracticesI hereby acknowledge that I have received a copy of Badia Hand to Shoulder Center Notice of Privacy Practices as required by federal law.Patient Consent for use and disclosure of Protected Health InformationI authorize the office Badia Hand to Shoulder Center to disclose protected health information to the following:Name and relationship of person(s) authorized to receive informationTelephone MessagesPlease choose one:I authorize the office of Badia Hand to Shoulder Center to leave telephone messages regarding my protected health information on the voicemail or answering machine.(Required)YesNoConsent to photographI authorize Badia Hand to Shoulder, LLC and its affiliates to take pictures of my (or my child’s) medical or surgical procedure(s) and condition(s) and to the use of such pictures for treatment, scientific, educational or research purposes.By signing below, I certify that I have read, understand, and agree to all four Notices above Mutual AgreementDr. Alejandro Badia, M.C., and Badia Hand to Shoulder Center (collectively labeled “physician”) agree to provide treatment to:Patient’s name (“patient”). The Physician takes pride in being able to extend a greater degree of privacy than is required by law.Federal and State privacy laws are complex. Unfortunately, some medical offices try to find loopholes around these laws. For example, physicians are forbidden by law from receiving money for selling lists of patients or medical information to companies to market their products or services directly to patients without authorization. Some medical practices, though, can lawfully circumvent this limitation by having a third party perform the marketing. While personal data is never technically in the possession of the company selling its products or services, the patient can still be targeted with unwanted marketing information. Physician believes this is improper and may not be in the patient’s best interest. Accordingly, Physician agrees not to provide medical information for the purposes of marketing directly to Patient. Regardless of legal privacy loopholes, Physician will never attempt to leverage its relationship with Patient by seeking Patient’s consent for marketing products for others.Patient and Physician acknowledge that breach of this Agreement may result in serious, irreparable harm. Patient and Physician agree to the right of equitable relief (including but not limited to injunctive relief). Should a breach of this Agreement result in litigation, the prevailing party in the litigation shall be entitled to reasonable costs, expenses, and attorney fees associated with the litigation.Agreement as to Resolution of Concerns“I”, “Patient/Guardian” shall be understood to mean Patient’s name "Physician" shall be understood to mean Alejandro Badia, M.D. / Badia Hand to Shoulder Center.Further, I understand that I am entering into a contractual relationship with Physician for professional care. I further understand that meritless and frivolous claims for medical malpractice have an adverse effect upon the cost and availability of medical care, and may result in irreparable harm to a medical provider. As additional consideration for professional care provided to me by Physician, I, the patient/guardian and/or my representative agrees not to advance, directly or indirectly, any false, meritless, and/or frivolous claim(s) of medical malpractice against Physician.Furthermore, should a meritorious medical malpractice cause or cause of action be initiated or pursued, I and/or my representative agree to use American Board of Medical Specialties (“ABMS”) board-certified expert medical witness(es) in the same specialty as Physician. Furthermore, I agree that these witnesses will be members in good standing of, and adhere to the guidelines and/or code of conduct, defined for expert witnesses by the ASSH and AAOS. In further consideration for this, Physician agrees to the same stipulations.Patient/guardian and Physician acknowledge that monetary damages may not provide an adequate remedy for breach of this Agreement. Such breach may result in irreparable harm to Physician’s reputation and business. Patient/guardian and Physician agree in the event of a breach to allow specific performance and/or injunctive relief.Credit Card AuthorizationSuccessful treatment depends not only on the skill of your physician, but on the commitment, attendance and efforts of you, the patient, as well. At Badia Hand to Shoulder Center we pride ourselves on working with our patients in a timely manner so that the treatment process has the most minimal impact on our patients’ precious time. In addition, your timely attendance is important to facilitating short wait times and optimal patient flow.The staff at Badia Hand to Shoulder Center is committed to accommodating your scheduling needs. In return, Badia Hand to Shoulder Center expects 24 hours’ notice prior to rescheduling or canceling an appointment. Any appointments cancelled or rescheduled without 24 hour notice will be assessed a $50.00 fee. This fee also applies to appointments in which a patient fails to attend or call. Our office has set this time aside to accommodate the schedule, and without proper notice, we are unable to provide the opportunity to another patient who may have requested the same time.For workers compensation patients, should your workers compensation insurance refuse to pay this fee due to your negligence, you will be responsible for this fee.I have read the cancellation policy and understand that I will be responsible to pay a cancellation/no show fee of $50.00 as indicated above. I authorize Badia Hand to Shoulder Center to charge a one-time fee of $50.00 to the credit card on file for each appointment missed. I understand that I will not be informed prior to this fee being charged to my account. I understand that if I give at least 24 hours advanced notice of cancelling an appointment, this fee will not be charged from my account. I understand that if I do not provide my credit card information to Badia Hand to Shoulder Center, I will still be responsible for this fee, and will be billed for this fee. NEW PATIENT MEDICAL HISTORY FORMPatient name(Required) Weight RaceAfrican AmericanAsianCaucasianNative American/AlaskanPacific IslanderOtherDecline to AnswerEthnicityHispanicNon-HispanicDecline to AnswerPreferred languageEnglishSpanishPreferred pharmacy's name: Preferred pharmacy's phone:Chief ComplaintDominant hand (the hand you write with):(Required)RightLeftAmbidextrousDescription of symptomsPainNumbness/TinglingFractureStiffnessOtherOther symptoms Bodypart affectedSelect Bodypart(Required)FingerHandWristElbowArmShoulderShoulderLeftRightUpper armLeftRightForearmLeftRightElbowLeftRightWristLeftRightHandLeftRightThumbLeftRightIndexLeftRightMiddleLeftRightRingLeftRightLittleLeftRightPain radiates from/to (i.e. from elbow to forearm) History of Present Illness1. Is your problem the result of an injury or accident?No injuryInjuryInjury at workAuto accidentSports injuryPrior surgeryWhen did the condition begin? MM slash DD slash YYYY 2. Are you represented by an attorney?(Required)YesNoAttorney name 3. Have you had a problem like this before?(Required)YesNoIf so, please describe 4. Have you been seen in an ER or urgent care for this problem?(Required)YesNoTreating ER/Urgent Care Date MM slash DD slash YYYY 5. Rate the pain (10 being the most pain)(Required)0123456789106. Do the symptoms wake you from sleep?(Required)YesNo7. Please describe the symptomsSharpDullStabbingThrobbingAchingBurningShooting8. What is the timing of the symptoms?(Required)ConstantIntermittent (comes and goes)9. Is the problem getting better or worse?Getting betterGetting worseUnchanged10. What makes the symptoms worse?TwistingMovingLying in bedAthleticsGrippingLiftingReaching overhead11. Are there any other symptoms associated with this problem?RednessBruisingSwellingNumbness/tinglingStiffnessClickingLockingPoppingWeakness12. Briefly describe how your symptoms began or how the injury occurred Prior Testing/TreatmentHave you had any prior tests for this problem?(Required)NoneX-raysMRICTNerve testing (NCV/EMG)Have you had any prior treatment for this problem(Required)YesNoType of treatment - Status of symptoms after treatment - Date(s) of treatmentIceImprovedWorsenedUnchangedDate(s) of treatment HeatImprovedWorsenedUnchangedDate(s) of treatment RestImprovedWorsenedUnchangedDate(s) of treatment NSAIDsImprovedWorsenedUnchangedDate(s) of treatment Muscle RelaxersImprovedWorsenedUnchangedDate(s) of treatment ChiropractorImprovedWorsenedUnchangedDate(s) of treatment Physical TherapyImprovedWorsenedUnchangedDate(s) of treatment Home ExercisesImprovedWorsenedUnchangedDate(s) of treatment SurgeryImprovedWorsenedUnchangedDate(s) of treatment InjectionsImprovedWorsenedUnchangedDate(s) of treatment BracingImprovedWorsenedUnchangedDate(s) of treatment TENS unitImprovedWorsenedUnchangedDate(s) of treatment Other treatments/Comments(Required) Select all previous hospitalizations/surgeriesNoneBrain surgeryHysterectomyAortic bypass/vascular surgeryLAP Band/Gastric BypassAppendectomyTonsillectomyCataract surgeryMastectomyHeart surgeryMalignancy/cancerHernia repairStentsCholecystectomy (gallbladder removal)Orthopedic surgeriesArthroscopy: kneeLeftRightArthroscopy: shoulderLeftRightCarpal tunnel releaseLeftRightRotator cuff repairLeftRightTotal hip replacementLeftRightTotal knee replacementLeftRightTotal shoulder replacementLeftRightSpinal surgery: indicate level Other surgery:Medical QuestionsMark all that currently apply:Metal in bodyClaustrophobicPregnantSleep apneaUses a CPAPSnoresAre you taking blood thinners?YesNoReview of SymptomsPlease indicate if you have experienced any of the following symptoms in the last 6 months:None for all1.Weight lossLoss of appetiteFatigueNone2.Blurred VisionDouble VisionVision LossNone3.Hearing lossHoarsenessTrouble swallowingNone4.Chest painPalpitationsNone5.Chronic coughPneumoniaShortness of breathNone6.HeartburnNausea/vomitingBlood in stoolNone7.Painful urinationBlood in urineKidney problemsNone8.Frequent rashesSkin ulcersPsoriasisNone9.Frequent fallsLoss of coordinationNumbnessChange in bowelChange in bladderDizzinessNone10.Sleep disorderDepression/anxietyDrug/alcohol addictionNone11.FeverNight sweatsHeat/cold intoleranceNone12.Easy bleedingEasy bruisingAnemiaNoneComments Family HistoryHave any direct relatives had any of the following disorders?None for allFatherNoneDiabetesHeart diseaseHypertensionBleeding problemsEpilepsyConnective tissueMuscular dystrophyStrokeOsteoporosisRheumatoid arthritisCancerComments MotherNoneDiabetesHeart diseaseHypertensionBleeding problemsEpilepsyConnective tissueMuscular dystrophyStrokeOsteoporosisRheumatoid arthritisCancerComments SiblingNoneDiabetesHeart diseaseHypertensionBleeding problemsEpilepsyConnective tissueMuscular dystrophyStrokeOsteoporosisRheumatoid arthritisCancerComments Social HistoryDo you smoke tobacco?Current, every day smokerCurrent, some day smokerFormer smokerHeavy tobacco smokerLight tobacco smokerNeverDo you drink alcohol?DailyOccasionallyRarelyNeverMarital statusMarriedSingleDivorcedWidowedDomestic partnershipAre you currently working?YesNoRetiredDisabledStudentIf yes: Occupation Employer If no, what date did you last work? MM slash DD slash YYYY Please list any work restrictions, if any AllergiesDo you have any allergies?(Required)YesNoIf yes, please list belowMedication, relevant food, or “seasonal”ReactionMedicationPlease list all medications you take on a regular basisNoneMedication - Dose and frequency (i.e. 20mg, once daily)Medical HistoryDo you have a personal history of any of the following?NoneAneurysmEmphysemaKidney diseaseAngina (chest pain)EpilepsyKidney stonesArthritisHeart attackMRSA infectionAsthmaHepatitisPacemakerBone/joint infectionHIV/AIDSPhlebitis/blood clotsCancerHigh cholesterolPulmonary embolismChemotherapy/radiationHypertensionReaction to anesthesiaCOPDHyperthyroidismSeizuresCongestive heart failureHypothyroidismStomach ulcersDiabetesStroke/TIATuberculosisAneurysm location Arthritis type Hepatitis type Cancer type Diabetes type Last A1C Please list any other conditions or details of conditions marked aboveSignature(Required)Reset signatureSignature locked. Reset to sign againDate(Required) MM slash DD slash YYYY Δ