Elevated Health NYC - Federal Worker Intake Form

Elevated Health NYC

Welcome to Elevated Health NYC, the leading specialists in Federal Workers’ Compensation injuries in NYC, and we are here to help you with all of your work-related injuries. Please understand that any chronic health problems are best addressed by your primary care provider, so our clinicians will not be providing treatment for chronic conditions EXCEPT musculoskeletal-related conditions during the exam. In keeping with these standards and to promote continuity of care, it is very important for us to know your medical history. Please complete all of the below information prior to arriving for your appointment. Exams may need to be rescheduled for patients who do not complete all of the following forms.

Personal Information

Patient First Name

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Patient Last Name

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Date of Birth

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Age

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Last 4 of SSN

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Street Address

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City

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State

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Zip Code

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Phone Number

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Occupation

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Employer

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Referral Source

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Insurance Information

I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this Office will prepare any necessary reports and forms to assist me in getting my case accepted and in turn collecting payment from the Department of Labor.

However, in the event that my case is not accepted, I understand that this office will attempt to bill my private insurance company and any amount authorized will be paid directly to this Office, and will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, or ignore requests to submit the necessary paperwork to pursue my case, any fees for professional services rendered to me will be immediately due and payable.

I agree to the terms above

Insurance Provider

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Other

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Policy ID

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Policy #

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Pain Chart

Please Describe the pain that you are feeling - list the body part(s), the sensation you are feeling, and the intensity on a scale of 1-10.

What pain are you feeling?

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Medical History

Check the conditions below that apply to you and describe them in the text box below:

Asthma

Abdominal Disorders

Alcohol Abuse

Allergies

Arthritis

Blood Disorder (Clots, Bleeding tendency)

Cancer

Cardiac Issues

Dental Disease

Diabetes

Drug Abuse

Emphysema

Eye Disease

Gallbladder Disease

Gastrointestinal Disorder (Acid Reflux, Hemorrhoids, Ulcer)

Glaucoma

Gynecological Disorder

Heart Disease

Hearing Defect

Hepatitis

High Blood Pressure

High Cholesterol

Kidney Disorder

Liver Disease

Mental Illness (Anxiety, Depression, Eating Disorder)

Muscular Disease

Neurological Issues (Migraines, Seizure, Stroke)

Nervous System Disorder

Obstructive Pulmonary Disease

Prostate Disease

Rheumatic Disease

Skin Disorder

Sleep Disorders (Apnea, Narcolepsy)

Sexually Trasnmitted Disease

Thyroid Disorder

Tuberculosis

Ulcer

Vein Disorder (Varicose)

Other

Please describe any conditions you've checked above:

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List any surgeries, including specific dates or age at time of surgery:

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List any hospitalizations, including dates of and reasons for hospitalization:

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List any prescription medications (w/ dosage and frequency of use) you are now taking:

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List any self-prescribed medications, dietary supplements, or vitamins (w/ dosage and frequency of use) you are now taking:

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List any drug or medical materials (i.e. latex) allergies and reaction:

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Review of Symptoms

Check if you currently have or have had any of the following:

Abdominal Pain

Abnormal Stool

Back Pain

Blood in Urine

Blurred Vision

Chest Pain

Change in Bowel Habits

Change in Size/Color of Mole

Coughing up Blood

Constipation

Difficulty Sleeping

Difficulty Swallowing

Dizziness

Diarrhea

Eye Pain

Ear Pain

Fainting

Fatigue

Fevers

Frequent Cough

Headache

Hearing Loss

Hoarse Voice

Inability to Sleep Flat

Indigestion

Joint Pain

Lightheadedness

Mood Changes

Muscle Cramps

Muscle Weakness

Nausea

Neck Pain

Night Sweats

Nosebleeds

Numb/Tingling

Palpitations

Persistent Bruising

Rash

Ringing in Ears

Rectal Pain

Sexual Dysfunction

Shortness of Breath

Skin Color Changes

Sore Throat

Stress

Swollen Glands

Swollen Joints

Tremors

Urine Infection

Weight Gain/Loss

Wheezing

Vomiting

Other

Additional Health History Comments:

Please complete this field.

Injury Questionnaire

For Traumatic Injuries (CA1), answer Question 1 ONLY.
For Repetitive Conditions (CA2), answer Questions 1 through 4

1. Describe with as much detail as possible the employment-related activities which you believe contributed to your injury/condition.

Please complete this field.

2. When did you first notice this condition? Has it come and gone, or has it been present continuously? What symptoms have you experienced?

Please complete this field.

3. Have you sought out medical attention for this injured body part in the past? If yes, when?

Please complete this field.

4. Do you have any other jobs or hobbies that could have contributed to this injury?

Please complete this field.

Patient Consent For Use & Disclosure of Protected Health Information

I hereby give my consent for Elevated Health NYC to use and disclose protected health information about me to carry out treatment, payment and healthcare operations. Elevated Health NYC Notice of Privacy Practices provides a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. Rock Professional offices reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to:

Elevated Health NYC 315 Madison Avenue, Suite 801 New York, NY 10017

With this consent form, Elevated Health NYC may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out treatment, payment and healthcare operations such as appointment reminders, insurance items and any calls pertaining to my clinical care including laboratory results, among others.

With this consent form, Elevated Health NYC may mail to my home or other alternative location any items that assist in carrying out treatment, payment, or healthcare operations such as appointment reminder cards and patient statements as long as they are marked personal and confidential.

With this consent form, Elevated Health NYC may email to my home or other alternative location at any time to assist the practice in carrying out treatment, payments, or healthcare operations such as appointment reminders. I have the right to request that Elevated Health NYC restrict how it uses or discloses my PHI to carry out treatments, payments and healthcare operations. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to Elevated Health NYC use and disclosure of PHI to carry out treatment, payment and healthcare operations.

I may revoke my consent in writing except to the extent the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent or later revoke it, Elevated Health NYC may decline to provide treatment to me.

I agree to the terms above

Notice of Privacy Practices Acknowledgement

I understand that under the Health Insurance Privacy & Accountability Act of 1996 (HIPAA) I have certain rights to privacy regarding my protected health insurance. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment directly and indirectly.

Obtain payment from third party payers.

Conduct normal healthcare operations such as quality assessments and physician certification.

I acknowledge that I have reviewed your Notice of Privacy Practice containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do not agree that you are bound to abide by such restrictions.

I agree to the terms above

Federal Injury Center Patient Agreement

As a Federal Injury Center, our entire staff at Elevated Health is dedicated to helping you get your work-related injury treated and you back to work as soon as possible. There are certain things that we can take care of for you on our end, and certain things that you will have to take care of on your end, in order to get your case approved in a timely manner.

Please review and initial the following statements to show your understanding of our Patient Policies:

I understand I am required to provide this office ALL documentation whether sent to my agency by me or my representative or received from my agency irrespective of whether I believe it to be important or not so it may be reviewed for action items and added to my file.

I understand I am required to provide this office ALL documentation whether sent to OWCP by me or my representative or received from OWCP irrespective of whether I believe it to be important or not so it may be reviewed for action items and added to my file.

I understand my treatment may be terminated, paused or postponed should I not provide all documentation required of me for the acceptance of my case. I will promptly respond to any and all inquiries from my agency and OWCP.

I understand this office bills OWCP directly for my care after the claim has been approved by OWCP. The issuing of a claim number does not mean or indicate your claim has been accepted by OWCP. Should I not provide documentation to this office which is required for approval (employee statements/narrative, factual data, information requests, imaging and diagnostic information, denial letters, reconsideration request forms, appeal forms etc.) or timely processing of my claim that I will be personally liable for any and all fees associated with my care. I understand I simply need to provide all requested documentation or information in order to not be personally liable for any and all fees.

I understand it is my responsibility to call OWCP to verify the receipt of documentation, case status updates and at the request of the staff.

I understand that while this office will help in assisting me with my claim and provide claim management it is ultimately my responsibility to provide my agency and OWCP with requested information and documentation. I will provide my agency with all CA-17 Duty Status Reports and all supporting documentation when submitting claims for compensation by use of form CA-7 and CA-7a. I further understand that all information provided to me as claim management is not legal advice and does not replace the advice of an attorney.

Patient Appointment Policy Agreement

As a Federal Injury Center, our entire staff at Elevated Health is dedicated to helping you get your work-related injury treated and your case approved. In order for us to assist you with these efforts, we need you to attend all of your scheduled appointments in a timely manner.

Please review and initial the following statements to show your understanding of our Patient Appointment Policies:

I understand that missing appointments will impact my case negatively, and therefore, I will attempt to attend all my appointments at their scheduled time.

I understand that I am required to arrive for my FIRST appointment 30 minutes prior to my scheduled time. This time is to compensate for any initial paperwork that needs to be completed at the time of my visit.

I understand that if I am more than 30 minutes late to any of my scheduled appointments, the office has the right to reschedule my appointment for another day/time.

If I can no longer make a scheduled appointment, I will call the office at least 24 hours in advance of my appointment in order to reschedule at the next available time.

I understand that if I cancel within 24 hours OR do not show up for my appointment without notice a maximum of 3 times, my future services at Elevated Health NYC may be terminated indefinitely.

I completely understand the above and have asked any questions needed for clarification prior to signing this form.

Final Signature

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date

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