New Patient Packet Step 1 of 10 10% Name* First Middle Last Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemaleOtherSocial SecurityPrimary Residence* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneHome PhoneCell Phone*Work PhoneUSA Phone Number (if any)Local Phone (Your Country #)*E-mail Address* How did you first learn about Dr. Badia?*- Select One -Family or FriendsSearch Engine (i.e. Google, Yahoo, etc.)Social Media- Facebook- Twitter- Google +- OtherTV/RadioMagazine/NewspaperOther (Please specify below)Other:Workers Comp or Auto InsuranceCompany NameAddress for claims Street Address City State / Province / Region ZIP / Postal Code Adjuster NamePhonePhonePrimary InsuranceCompany NamePhonePhonePolicy numberGroup numberPolicy holder nameDate of birth Date Format: MM slash DD slash YYYY Social security numberRelationship to patientSecondary InsuranceCompany NamePhonePhonePolicy numberGroup numberPolicy holder nameDate of birth Date Format: MM slash DD slash YYYY Social security numberRelationship to patientPrimary Care PhysicianPhysician NamePhonePhoneEmergency ContactContact NameRelationshipPhonePhoneAddressDo 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. Financial Policy This is an agreement between Badia Hand to Shoulder Center, as creditor, and the Patient/Debtor named on this form. By executing this agreement, you are agreeing to pay for all services that are received. Payment is expected at the time services are rendered. We accept cash, personal check, money order, cashier’s check, Visa and Master Card. We collect copay, coinsurance and any deductible at the time services are rendered. Insurance: Insurance is a contract between you and your insurance company. We will file insurance claims only for plans with whom we have a contract with. We participate in some managed care plans. 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 for claims submissions. All copay, coinsurance and deductibles are due at the time services are rendered. 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. 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 have to 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. Copying of records: You will need to request in writing, and pay a reasonable copying fee ($1/page for the first 25 pages and 25 cents for every page thereafter) if you want to have copies of your records 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 in CD and are subject to a $10.00 fee per disc. Consent to photograph: I 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. Effective date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect. My signature below certifies that I have read (or the form has been read to me) and I understand the contents on this form.Responsible party (if not the patient) Acknowledgement of Privacy Practices I 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 Information I 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 Messages Please 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.*YesNoConsent to photograph I 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. Mutual Agreement Dr. Alejandro Badia, M.C., and Badia Hand to Shoulder Center (collectively labeled “physician”) agree to provide treatment to:(“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. We want your feedback. If our office gets it right, tell us. If we could do something better, tell us. We take quality improvement seriously. While there are scores of “rating sites” in cyberspace, many fail to provide useful information. Let’s get it done right. We can make recommendations as to which sites follow minimum standards for fairness and balance. Just ask us. Physician has invested significant financial and marketing resources in developing the practice. Nothing in this Agreement prevents a patient from posting commentary about the Physician – his practice, expertise, and/or treatment – on web pages, blogs, and/or mass correspondence. In consideration for treatment and the above noted patient protection, if patient prepares such commentary for publication on web pages, blogs, and/or mass correspondence about Physician, the Patient exclusively assigns all Intellectual Property rights, including copyrights, to Physician for any written, pictorial, and/or electronic commentary. This assignment shall be operative and effective at the time of creation (prior to publication) of the commentary. This agreement shall be in force and enforceable for a period of five years from Physician’s last date of service to Patient. As a matter of office policy, Physician is requiring all patients sign the Mutual Agreement so as to establish that any anonymous or pseudonymous publishing or airing of commentary will be covered by this agreement for all Physician’s patients. Further, this agreement will survive for a minimum of three years beyond any termination of the Physician-Patient relationship. 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. Patient has been given the opportunity to ask questions and receive satisfactory and adequate explanations. Agreement as to Resolution of Concerns “I”, “Patient/Guardian” shall be understood to mean "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 Authorization Successful 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*WeightRaceAfrican 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):*RightLeftAmbidextrousDescription of symptoms Pain Numbness/Tingling Fracture Stiffness Other Other symptomsBody part affectedShoulder Left Right Upper arm Left Right Elbow Left Right Forearm Left Right Wrist Left Right Hand Left Right Thumb Left Right Index Left Right Middle Left Right Ring Left Right Little Left Right Pain radiates from/to (i.e. from elbow to forearm) History of Present Illness1. Is your problem the result of an injury or accident? No injury Injury Injury at work Auto accident Sports injury Prior surgery When did the condition begin? Date Format: MM slash DD slash YYYY 2. Are you represented by an attorney?*YesNoAttorney name3. Have you had a problem like this before?*YesNoIf so, please describe4. Have you been seen in an ER or urgent care for this problem?*YesNoTreating ER/Urgent CareDate Date Format: MM slash DD slash YYYY 5. Rate the pain (10 being the most pain)*0123456789106. Do the symptoms wake you from sleep?*YesNo7. Please describe the symptoms Sharp Dull Stabbing Throbbing Aching Burning Shooting 8. What is the timing of the symptoms?*ConstantIntermittent (comes and goes)9. Is the problem getting better or worse?Getting betterGetting worseUnchanged10. What makes the symptoms worse? Twisting Moving Lying in bed Athletics Gripping Lifting Reaching overhead 11. Are there any other symptoms associated with this problem? Redness Bruising Swelling Numbness/tingling Stiffness Clicking Locking Popping Weakness 12. Briefly describe how your symptoms began or how the injury occurred Prior Testing/TreatmentHave you had any prior tests for this problem?* None X-rays MRI CT Nerve testing (NCV/EMG) Have you had any prior treatment for this problem*YesNoType of treatment - Status of symptoms after treatment - Date(s) of treatmentIce Improved Worsened Unchanged Date(s) of treatmentHeat Improved Worsened Unchanged Date(s) of treatmentRest Improved Worsened Unchanged Date(s) of treatmentNSAIDs Improved Worsened Unchanged Date(s) of treatmentMuscle Relaxers Improved Worsened Unchanged Date(s) of treatmentChiropractor Improved Worsened Unchanged Date(s) of treatmentPhysical Therapy Improved Worsened Unchanged Date(s) of treatmentHome Exercises Improved Worsened Unchanged Date(s) of treatmentSurgery Improved Worsened Unchanged Date(s) of treatmentInjections Improved Worsened Unchanged Date(s) of treatmentBracing Improved Worsened Unchanged Date(s) of treatmentTENS unit Improved Worsened Unchanged Date(s) of treatmentOther treatments/Comments* Select all previous hospitalizations/surgeries None Brain surgery Hysterectomy Aortic bypass/vascular surgery LAP Band/Gastric Bypass Appendectomy Tonsillectomy Cataract surgery Mastectomy Heart surgery Malignancy/cancer Hernia repair Stents Cholecystectomy (gallbladder removal) Orthopedic surgeriesArthroscopy: knee Left Right Arthroscopy: shoulder Left Right Carpal tunnel release Left Right Rotator cuff repair Left Right Total hip replacement Left Right Total knee replacement Left Right Total shoulder replacement Left Right Spinal surgery: indicate levelOther surgery:Medical QuestionsMark all that currently apply: Metal in body Claustrophobic Pregnant Sleep apnea Uses a CPAP Snores Are you taking blood thinners?YesNoReview of SymptomsPlease indicate if you have experienced any of the following symptoms in the last 6 months: None for all 1. Weight loss Loss of appetite Fatigue None 2. Blurred Vision Double Vision Vision Loss None 3. Hearing loss Hoarseness Trouble swallowing None 4. Chest pain Palpitations None 5. Chronic cough Pneumonia Shortness of breath None 6. Heartburn Nausea/vomiting Blood in stool None 7. Painful urination Blood in urine Kidney problems None 8. Frequent rashes Skin ulcers Psoriasis None 9. Frequent falls Loss of coordination Numbness Change in bowel Change in bladder Dizziness None 10. Sleep disorder Depression/anxiety Drug/alcohol addiction None 11. Fever Night sweats Heat/cold intolerance None 12. Easy bleeding Easy bruising Anemia None Comments Family HistoryHave any direct relatives had any of the following disorders? None for all Father None Diabetes Heart disease Hypertension Bleeding problems Epilepsy Connective tissue Muscular dystrophy Stroke Osteoporosis Rheumatoid arthritis Cancer CommentsMother None Diabetes Heart disease Hypertension Bleeding problems Epilepsy Connective tissue Muscular dystrophy Stroke Osteoporosis Rheumatoid arthritis Cancer CommentsSibling None Diabetes Heart disease Hypertension Bleeding problems Epilepsy Connective tissue Muscular dystrophy Stroke Osteoporosis Rheumatoid arthritis Cancer CommentsSocial 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: OccupationEmployerIf no, what date did you last work? Date Format: MM slash DD slash YYYY Please list any work restrictions, if any AllergiesDo you have any allergies?*YesNoIf yes, please list belowMedication, relevant food, or “seasonal”ReactionMedicationPlease list all medications you take on a regular basis None Medication - Dose and frequency (i.e. 20mg, once daily)Medical HistoryDo you have a personal history of any of the following? None Aneurysm Emphysema Kidney disease Angina (chest pain) Epilepsy Kidney stones Arthritis Heart attack MRSA infection Asthma Hepatitis Pacemaker Bone/joint infection HIV/AIDS Phlebitis/blood clots Cancer High cholesterol Pulmonary embolism Chemotherapy/radiation Hypertension Reaction to anesthesia COPD Hyperthyroidism Seizures Congestive heart failure Hypothyroidism Stomach ulcers Diabetes Stroke/TIA Tuberculosis Aneurysm locationArthritis typeHepatitis typeCancer typeDiabetes typeLast A1CPlease list any other conditions or details of conditions marked aboveSignature*Date* Date Format: MM slash DD slash YYYY