History of Present Illness
History of Present Illness (continued)
Prior Testing / Treatment
Type of treatment
Status of symptoms after treatment (select only those that apply)
Date of treatment
Orthopedic on side:
Review of Systems
On the drawing below, mark an X where the pain is the worst.
Use the symbols below to show where you are having different kinds of pain:
If Yes, please list below:
Please list the name of a person to contact in case of an emergency other than a spouse or patient:
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE AND CONSENT TO USE HEALTH INFORMATION
Read before signing the Acknowledgement and Consent
This acknowledgement of notice and consent authorizes ALL-PRO ORTHOPEDICS AND SPORTS MEDICINE P.A. to use health information for treatment, payment, and health care operations purposes.
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 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 obtain a revised notice by submitting a written request to our Privacy Officer.
How to contact our Privacy Officer
Mail: 17779 SW 2nd St, Pembroke Pines, FL 33029Tel: 954-322-1110/ Fax: 954-322-1099
Acknowledgement and Consent
for treatment, payment, and healthcare operations purposes consistent with its Notice of Privacy Practices.
Personal representative information (if applicable):
IDENTITY OF RECIPIENTS: Provide the name or other specific identification of the person(s) or class of persons to whom the covered entity may disclose covered information:
ASSIGNMENT OF BENEFITS
for any service and/or changes 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 the ASSIGNMENT OF BENEFITS, I hereby instruct the insurance carrier that in the event the medical benefits are disputed 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 aside and not disbursed until the dispute is resolved.
OUR CANCELLATION / NO-SHOW POLICY
DUE TO THE INCREASING NUMBER OF NO-SHOW AND SAME DAY CANCELLATIONS OF APPOINTMENTS, WE ARE INSTITUTING A NEW POLICY, EFFECTIVE IMMEDIATELY.
THE POLICY IS AS FOLLOWS:
1. Cancelled appointments within 24 hours of appointment time -$25.00 fee.
2. No show for appointment time -$50.00 fee.
3. Surgery cancellation within five days of schedule surgery time -$750.00 fee.
4. Any forms or letters will charge accordingly.
OUR STAFF APPRECIATES YOUR UNDERSTANDING
*** Medicare patients.: Please be aware that you will be responsible for the 20% co-insurance amount applied by Medicare upon adjudication of your claim. ***
Article 1: Agreement to Arbitrate: The patient and All-Pro Orthopedics And Sports Medicine, P.A., the undersigned Medical Care Provider ("MCP") - which includes any affiliated physicians, employees, any related medical group, professional association, or any other entity or individual which has provid-ed medical services in conjunction with the MCP - agree to submit any dispute whatsoever to bind-ing arbitration including without limitation any claim for malpractice, personal injury, battery, breach of express or implied contract, loss of consortium, wrongful death or any payment or any other disputes relating in any way to past, present or future medical care. Any dispute will go to binding arbitration.
Article 2: All Claims Must be Arbitrated: The patient, and/or his or her spouse, born or unborn children, parents, heirs, or anyone launching any legal or equitable action (hereinafter "the Patient") and the MCP agree that any complaint of any type which in any way. relates to medical services shall, without exception, be submitted to binding arbitration. The governing law shall be the Federal Arbitration Act, state law notwithstanding. It is the express intention of the parties that any and all claims or complaints of any kind shall be submitted to and resolved by binding arbitration, which will be the exclusive and sole remedy. It is the specific and irrevocable intention of the parties to submit any question concern-ing this Agreement's arbitrability to the arbitrators only and to no other person or entity. For all issues regarding the validity of this - Agreement in court, the prevailing party shall be entitled to attorney's fees and to costs as determined by the court.
The MCP and any affiliated medical service provider that chooses to join in this Agrement agree to be equally bound just as the Patient is bound to binding arbitration in the event of any dispute. Such disputes can be brought by the MCP against the Patient, including terms of payment, services rendered, physical or emotional abuse, and other disputes. The Patient understands that any and all medical care provided is sufficient consideration, and the Patient will be fully and legally bound by this Agreement. Both parties to this Agreement are giving up their constitutional right to have any dispute decided in a court of law before a jury. All parties understand that that are giving up their right to have any dispute decided by a judge or jury through the court system. Resorting to the legal system by action at law or in equity will only be permissible if necessary to enforce any decisions reached through arbitration. The parties agree that any dispute about any provisions of this Agreement will be decided through arbitration.
The parties hereby bind anyone whose claims may arise out of or relate to treatment or services provided by the MCP at the time of the occurrence giving rise to the claim. In the case of any pregnant mother, the term "pattient" means both the mother and the mother's expected child or children. The parties consent to the participation in this arbitration of any person or entity that would otherwise be a proper additional party in a court action if they have been involved in any way in the care of the Patient. This may include claims of the Patient against other physicians, nurses or medical professionals, or a hospital or other facility. Additionally, this Agreement is intended to resolve all claims for vicarious liability of the MCP.
Article 3: Recovery: The signers agree that the maximum total amount of all noneconomic and eco-nomic damages combined shall never exceed $250,000.00, applied on a per case basis, regardless of the number of claimants seeking compensation, and regardless of the number of physicians, professional associations, employees or entities named as defendants. The Patient agrees to waive any and all rights to any higher award. This limitation applies regardless of whether another health-care provider, such as a physician, a hospital or other facility or employees of such a physician, hospi-tal or facility are named as defendants in binding arbitration or in any other proceedings. "Noneco-nomic damages" means nonfinancial losses that would not have occurred but for the injury giving rise to the cause of action, including pain and suffering, inconvenience, physical impairment, mental anguish, disfigurement, loss of capacity such damages under general law, including the Wrongful Death Act. The arbitrators may choose to award damages in excess of $250,000.00 only when extreme hardship is demonstrated: As consideration for the limitation on any waivers, the MCP will pay' up to and only the first $2,500.00 of attorney fees for the Patient.
The parties agree that if any punitive damages are awarded, they may not exceed three times any compensatory award. Same as required by Medicare/Medicaid, the parties aree that any awards in excess of $10,000.00 shall be paid in equal annual payments over ten (10) years without being reduced to present value. The arbitrators may reduce the time period in cases of extreme hardship. They will also consider any other collateral sources of compensation (e.g., workers comensation, life insurance, disability, charitable, and governmental benefits, and other monies paid to the injured patient or any other party) which shall diminish any awards for noneconomic and/or economic damag-es. The MCP shall be entitled to an off-set for any monies received by the Patient for claims against any other health care provider, if such claims arise out of or relate in any way to the claims of the Patient against the MCP. The parties agree to the complete disclosure of all collateral sources of com-pensation. Failure to promptly disclose any additional sources on request is agreed to be grounds for immediate and total dismissal of any claim.
Article 4: Statute of Limitations: In no case shall the statute of limitations exceed twelve (12) months from the date any alleged injury or problem could or should have been discovered regardless of the age of the Patient. The arbitrators and their empowerment under the FAA shall determine any ques-tion concerning the application of this provision. If this provision is held to be invalid it is replaced by the statute of limitations set forth in F.S. §766.
Article 5: Severability: If any specific term or provision of Agreement is determined by a court of competent jurisdiction to be illegal, invalid, or otherwise unenforceable, the entire remainder of this Agreement shall be construed to be in full force and effect, and all other provisions will still apply. The Parties agree in general that any provisions so challenged will be brought to the arbitrators to decide upon, and not to a judge or jury.
Article 6: Merger Clause: This Agreement represents the entire agreement made between the MCP and the Patient. It supersedes any other agreements between the Patient and the MCP. Except as expressly set forth herein, there are no other representations, promises, understandings, or agree-ments of any kind between the parties. The Patient signing this Agreement acknowledges that he or she has not relied in any way upon any oral or written statements made to them besides what is con-tained within this Agreement. All parties acknowledge and understand that this Agreement cannot be changed, altered or modified in any way except by an instrument in writing, signed by all parties.
Article 7: Pronouns and Headings: The singular shall be held to include the plural, the plural held to include the singular, and the use of any gender shall be held to include every gender. All headings, titles, sutitles, or captions are inserted for convenience only, and are to be ignored in any construc-tion of the provisions hereof.
Article 8: Procedures and Applicable Law: The parties agree to try to resolve all issues within nine (9) months of any complaint. This Agreement, its substantive provisions, the scope ..pfAh_e, Agreernent, the authority granted to the arbitrators.. and the.,linaitation contained in this Agreement, are to be governed by, and interpreted pursuant to the Federal Arbitration Act, any confilicting state law notwith-standing. To the extent not inconsistent with the FAA, it shall also be governed by provisions of the Revised Uniform Arbitration Act as adopted in the principal state where the MCP practices. The parties `agree that any dispute between them shall be determined by a panel of three arbitrators. Each party shall select one arbitrator from a list of qualified legal/medical experts provided by the MCP, All arbitrators will hold either Medical Degrees or both Medical and Ards Doctor Degrees. The two arbitrators selected shall then select a third arbitrator from the same list. Each party may remove the other's chosen arbitrator only once. The three arbitrators shall resolve any and all disputes between the parties pursuant to the National Arbitration Forum Code of Procedure or such procedures as they may jointly decide.
All arbitration hearings shall be conducted by video conference; the 'MCP will provide equipment and pay all costs of video conference bridging' and that of the arbitrators. The parties shall adopt rules of evidence such as the arbitrators may see fit. The MCP shall pay the full costs of the arbitration, but shall not be responsible for paying any fees or costs charged to the Patient by their attorney save the first $2,500.00 as incli-dated above. Reasonable discovery will be permitted by both sides. The parties agree that the arbitrators are to render a written decision with reasons stated for the decision. This agreeMent is to be construed to follow F.S §766 and provides patient with all rights necessary under F.S. §766 and the Florida Medical Malpractice Act. With the exceptions of a right to a trial by jury and the statute of limitations, if there is a conflict between this agreement and either F.S. §766 or the Florida Medical Malpractice Act then F.S. §766 or the Florida Medical Malpractice Act will prevail.
Article 9: Right of Counsel and Rescission: The Patient understands that this Agreement is a legal document, and the Patient has the right to consult with an attorney before signing if desired. Your MCP encourages you to consult an attorney prior to signing or during a fifteen (15) day rescission period. You may rescind this Agreement for fifteen (15) days after signing it; you agree that it will be in full force and effect until the date received at the MCP's office. To rescind it, return a copy to the MCP by certified mail-return receipt only with "CANCELED" written on the first page, and signed by you underneath that word. The Agreement will then be rescinded for all future care, but you agree it will be valid for any and all care provided by the MCP to the Patient for the entire period of all medical services up to the rescission.
Article 10: Authority to Sign: The Patient represents that he or she does have the authority to sign and execute this document on his/her own behalf (if signed by the Patient), or on behalf of the Patient (if signed by a person other than the Patient.)
Article 11: No Undue Influence: The individual signing this Agreement hereby acknowledges that he or she has not been pressured, induced, coerced, or intimidated in any way into signing this Agreement, and has signed it of his or her own free will and accord and not under duress of any kind, The parties agree that they have been given opportunity to ask questions and received answers concerning the specifics and intent of their Agreement.
Frivolous Legal Actions: The Patient agrees that under no circumstances will a frivolous action or claim be brought again St the MCP,. 6ridthe MCP agrees to not bring any frivolous action or claim against the Patient. If two or more Arbitrators rule that any action or claim brought against either party if frivolous in nature, the prevailing party shall be entitled to economic and noneconomic damages, including loss of wages or other conpensation, damage to reputation, full attorney's fees and punitive damages
Article 13: Mediation: At the MCP's sole expense, upon any compliant or alleged injury, the parties agree to promptly mediate in good faith with a qualified mediator prior to any arbitration hearing. A qualified professional mediator with medico-legal background shall be mutually agreed upon.
NOTICE: BY SIGNING THIS CONTRACT, YOU AGREE TO HAVE ANY ISSUE OF ALLEGED MEDICAL NEGLIGENCE OR BREACH OF CONTRACT BETWEEN YOU AND YOUR MCP DECIDED BY BINDING ARBITRATION IN WHICH BOTH PARTIES GIVE UP THEIR RIGHT TO A TRIAL BY JURY OR TRIAL BY A JUDGE.
I hereby agree that all provisions of this Agreement are in full effect, and no word, sentence, paragraph or provision may be crossed out, excised or removed.
Medical Records Release Form
By signing this form, I authorize you to release confidential health information about me, by releasing a copy of medical records or a summary or narrative of my protected health information, to the person (s) or entity below.
consent to the release of any positive or negative test results for AIDS or HIV infection, antibodies to AIDS or infection with any other causative agent of AIDS with the result of my medical records.
Release my protected health information to the following person(s) / entity:
give permission for these records to be faxed to the above entity