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Ortho.med.sc.edu


Thank you for scheduling an appointment with one of our physicians. It is our pleasure
to welcome you to the Department of Orthopaedic Surgery and Sports Medicine in
advance of your first visit.
The clinic is located at Two Medical Park, Lower Level, Suite L10.
Below are important items you need to look over prior to your first visit to our practice.
Some require action on your part.
Insurance Coverage: Please bring your insurance card to your scheduled appointment.
Without verification of your insurance coverage your appointment may be rescheduled,
or you will be expected to pay all fees at the time services are rendered.
If your insurance carrier requires referral authorizations, it is your responsibility to check
with your primary care physician to ensure they have authorized your visits to your
office. Without this authorization you will be expected to pay for the services you
receive, on the date of your appointment, in full.
Medical Information: Please have your medical records forwarded to us prior to your
appointment. We need to review these records which may include x-rays, MRI’s, bone
scans, and notes of visits to other physicians.
Please bring with you all medications you are currently taking so we can accurately
document this information in your patient chart.
Medical History Forms: Attached you will find medical history forms with need to be
completed prior to your visit at our office. These forms, completed in entirety, are
required in our office prior to being seen by any of our physicians. You may either bring
the completed forms with you on the day of your appointment or mail them if time
allows.
Minors under the Age of 18: Patients that are under the age of 18 must be accompanied
by a parent/legal guardian. If a parent/legal guardian is unavailable to attend the visit, the
form Consent to Medical Treatment and Responsibility for Medical Charges for Minors
must be filled out and given at time of check in.
Any of the above information that is missing on the day of your schedule appointment
may cause a reschedule of your appointment. Please arrive 30 minutes prior to your
scheduled appointment time. If you have any questions prior to your visit, please contact
our office by calling 803-434-6812.
Internet-kjh-1-07-09
DEPARTMENT OF ORTHOPAEDIC SURGERY
Two Medical Park, Suite 404, Columbia, SC 29203
803-434-6812, FAX 803-434-7306
www.uscortho.com/www.uscsportsmedicine.com
DATE___________________________
(Information About You)
Full Name_________________________________________________ Marital Status: Street Address_________________________________ City___________ Mailing Address_______________________________ City___________ Email Address_______________________________________________________________________________ Employer Address_____________________________ City______________ State_______ Zip _________ Date of Birth _____________ Social Security # ___ ____________ Driver’s License # ___________________ Nearest Relative Not Living With You ____ ____________________ Referred to this office b Do You Live In A Skilled Nursing Facility? Yes No (Information About Your Parent/Spouse)
Parent/Spouse’s Full Name_____________________________________________________________________ Parent/Spouse’s Employer_________________________________ Employer Address_____________________________ City______________ State_______ Zip__________ Parent/Spouse DOB_______________ Social Security # ___ _____________ Work Phone #______________ PRIMARY INSURANCE TO FILE
Insured’s Name__________________________________ Relationship to Patient ____________________ Insured’s Social Security # or ID #________________________________ Insurance Co. Name__________________________________ Insurance Co. Address__________________________ City______________ State_______ Zip__________ SECONDARY INSURANCE TO FILE
Insured’s Name__________________________________ Relationship to Patient ____________________ Insured’s Social Security # or ID #________________________________ Insurance Co. Name__________________________________ Insurance Co. Address__________________________ City______________ State_______ Zip__________ I understand that payment is due at the time service is rendered. I hereby authorize the release of any medical information to (1) an insurance company through which I claim benefits and (2) any physician involved in my medical care. I realize this authorization allows USCSOM Department of Orthopaedic Surgery to release any information to any of my insurers or physicians as requested by any such insurer or physician. I HEREBY ASSIGN ALL MEDICAL AND/OR SURGICAL BENEFITS TO WHICH I AM ENTITLED INCLUDING MEDICARE, PRIVATE INSURANCE, GROUP POLICY BENEFITS AND OTHER HEALTH PLANS TO USCSOM DEPARTMENT OF ORTHOPAEDIC SURGERY. USCSOM DEPARTMENT OF ORTHOPAEDIC SURGERY DOES NOT EXTEND CREDIT. I HEREBY AGREE TO PAY ALL COSTS AND REASONABLE ATTORNEY FEES IN THE EVENT THIS ACCOUNT IS TURNED OVER TO AN ATTORNEY FOR COLLECTION. Signature_________________________________________________ Date____________________________ Responsible Party Signature (if different) In order to better coordinate your health care needs and ensure other physicians involved with your care are
updated regarding your medical condition(s), please provide the following information:
REFERRING PHYSICIAN: (Who referred you to our practice?)
Doctor’s Name:
________________________________________________________________________ ________________________________________________________________________ _________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Would you like us to send copies of your medical records?

PRIMARY CARE PHYSICIAN/FAMILY PRACTICIONER:
Doctor’s Name:
________________________________________________________________________ ________________________________________________________________________ _________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Would you like us to send copies of your medical records?
SPECIALIST: (Cardiologist, Internal Medicine, Ob/Gyn, Derm

atologist, etc.)
________________________________________________________________________ ________________________________________________________________________ _________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Would you like us to send copies of your medical records?
ORTHOPAEDIST: (Have you seen any other Orthopaedic Physician?)
Doctor’s Name:
________________________________________________________________________ ________________________________________________________________________ _________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Would you like us to send copies of your medical records?

___________________________________
___________________________________ Patient Name (Printed) MEDICAL HISTORY QUESTIONNAIRE
Name_______________________________________________ Referring Physician_______________________
History of Present Illnes
Please explain your current problem. Include location of problem, how long you have experienced this problem, and the severity of the problem. Include what makes the problem worse or better and any associated signs or symptoms. ____ _______________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
Past History

List any medications you presently take: __________________________________________________________
____________________________________________________________________________________ List all illness/injuries/surgeries you have had that required hospitalization: ______________________________ ____________________________________________________________________________________ Do you have allergies to any medications? If yes, list medications you are allergic to: _________________________________________________________
Family History

Social History

Current Occupation ___
_______________________________________________________________________ If yes, how often? ________________________ If yes, how much a day? __________________ If yes, what kind? ________________________ Review of Systems (Please check box if Yes)
Patient Name: __________________________
General Gastrointestinal
Genitourinary
Cardiovascular Neurologic
Ear-Eyes-Nose-Throat Respiratory
Musculoskeletal

Explain all “YES” answers here:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
*OFFICE USE ONLY
_________________________________________ ____________________________________ Above History Updated (initial and date all changes to above information): Date Physician
Signature
Physician
Signature

Patient Name: ______________________________________________

Please answer, yes or no, to the following questions as they pertain to pre-authorization for anti-inflammatory
therapy.
1. Have you required Nonsteroidal anti-inflammatory therapy for more than 21 consectutive days? 2. Have you experienced intolerance with at least 2 other anti-inflammatory medications? (i.e. Motrin, 3. Do you have a history of peptic ulcer disease, Nonsteroidal anti-inflammatory related ulcer, GI bleed, or 4. Are you receiving drug therapy with corticosteroids, anticoagulants, antiplatlets, or methotrexate? 5. Are you currently receiving an H2 antagonist, proton pump inhibitor, or misoprotol (cytotec)? UNIVERSITY OF SOUTH CAROLINA SCHOOL OF MEDICINE UNIVERSITY SPECIALTY CLINICS® Authorization Regarding Payment and Release of Medical Information
I hereby authorize and request the payment of services from Medicare, Medicaid and/or other insurance plans or payers be made on my behalf to University Specialty Clinics – Orthopaedic Surgery. I hereby assign to University Specialty Clinics all payments for treatment services. I agree to allow University Specialty Clinics to file an appeal for me with Medicare, Medicaid and/or other insurance plans or payors for any reason. I understand and agree that I am responsible for paying any amount not covered by Medicare, Medicaid and/or other insurance plans or payers. I hereby authorize the release of medical information to Medicare, Medicaid and/or insurance plans or other payers. I also authorize the release of medical information to other healthcare providers including, but not limited to, my primary care or family physician, consulting physicians or healthcare providers, hospitals, rehabilitation centers, or other healthcare providers or facilities. I permit a copy of this authorization to be used. ___________________________________ Patient’s/Patient’s Representative’s Signature ____________________________________ __________________________________ Date ____________________________________ Printed Patient’s or Representative’s Name ____________________________________ Representative’s Relationship to Patient To be completed if a Student Athlete:
Authorization to Release Information to Coach or Athletic Trainer
I authorize the release of medical information to the coach or athletic trainer of the school listed below for the purpose of providing the best comprehensive care. I may revoke this authorization at any time. Such revocation must be in writing and delivered to University Specialty Clinics. The revocation will not apply to records and information that have already been disclosed. ______________________ ____________________________________________ __________________ Name of School Attending If under age 18, Parent or Legal Guardian’s (Students 18 years of age or older may sign authorization) DEPARTMENT OF ORTHOPAEDIC SURGERY
Two Medical Park, Suite 404, Columbia, SC 29203
803-434-6812, FAX 803-434-7306
www.uscortho.com/www.uscsportsmedicine.com
Consent to Treatment

I hereby agree to and give consent to the physicians, healthcare providers, associates,
consultants and residents of University Specialty Clinics to diagnose and treat me. I
consent to any and all treatment including, but not limited to, physical examinations,
psychological examination, x-rays, laboratory procedures, and other procedures related to
routine diagnosis and treatment as determined appropriate by the practices physicians,
healthcare providers, associates, consultants and residents.
____________________________________ Patient’s/Patients Representative’s Signature ____________________________________ ______________________________ Printed Patient’s or Representative’s Name Representative’s Relationship to Patient DEPARTMENT OF ORTHOPAEDIC SURGERY
Two Medical Park, Suite 404, Columbia, SC 29203
803-434-6812, FAX 803-434-7306
www.uscortho.com/www.uscsportsmedicine.com
University Specialty Clinics Notice of Privacy Practices

By signing below, I state that I have been given my own copy of the University
Specialty Clinics’ Notice of Privacy Practices, effective date 4/14/03.

____________________________________
Printed Name of Patient
____________________________________ Signature of Patient ____________________________________ Printed Name of Patient’s Representative ____________________________________ Signature of Patient’s Representative’s Description of Authority to Act on Behalf of Patient DEPARTMENT OF ORTHOPAEDIC SURGERY
Two Medical Park, Suite 404, Columbia, SC 29203
803-434-6812, FAX 803-434-7306
www.uscortho.com/www.uscsportsmedicine.com

Source: http://ortho.med.sc.edu/New.Patient.Registration.pdf

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