Patient Summary Form PSF-750 (Rev:2/18/2009) Patient Information

Transcription

1 atient Summary Form SF-750 (ev:2/18/2009) atient nformation Female nstructions lease complete this form within the specified timeline and fax to the specified fax number as indicated on lan Summary or plan information previously provided. atient name Last First M Male atient date of birth *Fax number may vary by plan. atient address City State Zip code atient insurance D# Health plan Group number eferring physician (if applicable) rovider nformation referral issued (if applicable) eferral number (if applicable) 1. Name of the billing provider or facility (as it will appear on the claim form) 2. Federal tax D(N) of entity in box #1 1 MD/DO 2 DC 3 4 O 5 Both and O 6 Home Care 7 AC 8 M 9 Other 3. Name and credentials of the individual performing the service(s) 4. Alternate name (if any) of entity in box #1 5. N of entity in box #1 6. hone number 7. Address of the billing provider or facility indicated in box #1 8. City 9. State 10. Zip code rovider Completes his Section: you want HS submission to begin: atient ype 1 New to your office 2 st d, new injury 3 st d, new episode 4 st d, continuing care Nature of Condition 1 nitial onset (within last 3 months) 2 ecurrent (multiple episodes of < 3 months) 3 Chronic (continuous duration > 3 months) Cause of Current pisode 1 raumatic 4 ost-surgical 2 Unspecified 5 Work related 3 epetitive 6 Motor vehicle Anticipated CM Level DC ONLY of Surgery { ype of Surgery 1 ACL econstruction 2 otator Cuff/Labral epair 3 endon epair 4 Spinal Fusion 5 Joint eplacement 6 Other Neck ndex Back ndex Diagnosis (CD code) lease ensure all digits are entered accurately Current Functional Measure Score DASH LFS (other) atient Completes his Section: (lease fill in selections completely) Symptoms began on: ndicate where you have pain or other symptoms: 1. Briefly describe your symptoms: 2. How did your symptoms start? 3. Average pain intensity: Last 24 hours: no pain worst pain ast week: no pain worst pain 4. How often do you experience your symptoms? 1 Constantly (76%-100% of the time) 2 Frequently (51%-75% of the time) 3 Occasionally (26% - 50% of the time) 4 ntermittently (0%-25% of the time) 5. How much have your symptoms interfered with your usual daily activities? (including both work outside the home and housework) 1 Not at all 2 A little bit 3 Moderately 4 Quite a bit 5 xtremely 6. How is your condition changing, since care began at this facility? 0 N/A his is the initial visit 1 Much worse 2 Worse 3 A little worse 4 No change 5 A little better 6 Better 7 Much better 7. n general, would you say your overall health right now is... 1 xcellent 2 Very good 3 Good 4 Fair 5 oor atient Signature: X :

2 Neck ndex ACN Group, nc. Form N-100 ACN Group, nc. Use Only rev 3/27/2003 atient Name his questionnaire will give your provider information about how your neck condition affects your everyday life. lease answer every section by marking the one statement that applies to you. f two or more statements in one section apply, please mark the one statement that most closely describes your problem. ain ntensity have no pain at the moment. he pain is very mild at the moment. he pain comes and goes and is moderate. he pain is fairly severe at the moment. he pain is very severe at the moment. he pain is the worst imaginable at the moment. Sleeping have no trouble sleeping. My sleep is slightly disturbed (less than 1 hour sleepless). My sleep is mildly disturbed (1-2 hours sleepless). My sleep is moderately disturbed (2-3 hours sleepless). My sleep is greatly disturbed (3-5 hours sleepless). My sleep is completely disturbed (5-7 hours sleepless). eading can read as much as want with no neck pain. can read as much as want with slight neck pain. can read as much as want with moderate neck pain. cannot read as much as want because of moderate neck pain. can hardly read at all because of severe neck pain. cannot read at all because of neck pain. ersonal Care can look after myself normally without causing extra pain. can look after myself normally but it causes extra pain. t is painful to look after myself and am slow and careful. need some help but manage most of my personal care. need help every day in most aspects of self care. do not get dressed, wash with difficulty and stay in bed. Lifting can lift heavy weights without extra pain. can lift heavy weights but it causes extra pain. if they are conveniently positioned (e.g., on a table). light to medium weights if they are conveniently positioned. can only lift very light weights. cannot lift or carry anything at all. Driving can drive my car without any neck pain. can drive my car as long as want with slight neck pain. can drive my car as long as want with moderate neck pain. cannot drive my car as long as want because of moderate neck pain. can hardly drive at all because of severe neck pain. cannot drive my car at all because of neck pain. Concentration can concentrate fully when want with no difficulty. can concentrate fully when want with slight difficulty. have a fair degree of difficulty concentrating when want. have a lot of difficulty concentrating when want. have a great deal of difficulty concentrating when want. cannot concentrate at all. ecreation am able to engage in all my recreation activities without neck pain. am able to engage in all my usual recreation activities with some neck pain. am able to engage in most but not all my usual recreation activities because of neck pain. am only able to engage in a few of my usual recreation activities because of neck pain. can hardly do any recreation activities because of neck pain. cannot do any recreation activities at all. Work can do as much work as want. can only do my usual work but no more. can only do most of my usual work but no more. cannot do my usual work. can hardly do any work at all. cannot do any work at all. Headaches have no headaches at all. have slight headaches which come infrequently. have moderate headaches which come infrequently. have moderate headaches which come frequently. have severe headaches which come frequently. have headaches almost all the time. ndex Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100 Neck ndex Score

3 Back ndex ACN Group, nc. Form B-100 ACN Group, nc. Use Only rev 3/27/2003 atient Name his questionnaire will give your provider information about how your back condition affects your everyday life. lease answer every section by marking the one statement that applies to you. f two or more statements in one section apply, please mark the one statement that most closely describes your problem. ain ntensity he pain comes and goes and is very mild. he pain is mild and does not vary much. he pain comes and goes and is moderate. he pain is moderate and does not vary much. he pain comes and goes and is very severe. he pain is very severe and does not vary much. Sleeping get no pain in bed. get pain in bed but it does not prevent me from sleeping well. Because of pain my normal sleep is reduced by less than 25%. Because of pain my normal sleep is reduced by less than 50%. Because of pain my normal sleep is reduced by less than 75%. ain prevents me from sleeping at all. Sitting can sit in any chair as long as like. can only sit in my favorite chair as long as like. ain prevents me from sitting more than 1 hour. ain prevents me from sitting more than 1/2 hour. ain prevents me from sitting more than 10 minutes. avoid sitting because it increases pain immediately. ersonal Care do not have to change my way of washing or dressing in order to avoid pain. do not normally change my way of washing or dressing even though it causes some pain. Washing and dressing increases the pain but manage not to change my way of doing it. Washing and dressing increases the pain and find it necessary to change my way of doing it. Because of the pain am unable to do some washing and dressing without help. Because of the pain am unable to do any washing and dressing without help. Lifting can lift heavy weights without extra pain. can lift heavy weights but it causes extra pain. ain prevents me from lifting heavy weights off the floor. if they are conveniently positioned (e.g., on a table). light to medium weights if they are conveniently positioned. can only lift very light weights. raveling get no pain while traveling. get some pain while traveling but none of my usual forms of travel make it worse. get extra pain while traveling but it does not cause me to seek alternate forms of travel. get extra pain while traveling which causes me to seek alternate forms of travel. ain restricts all forms of travel except that done while lying down. ain restricts all forms of travel. Standing can stand as long as want without pain. have some pain while standing but it does not increase with time. cannot stand for longer than 1 hour without increasing pain. cannot stand for longer than 1/2 hour without increasing pain. cannot stand for longer than 10 minutes without increasing pain. avoid standing because it increases pain immediately. Social Life My social life is normal and gives me no extra pain. My social life is normal but increases the degree of pain. ain has no significant affect on my social life apart from limiting my more energetic interests (e.g., dancing, etc). ain has restricted my social life and do not go out very often. ain has restricted my social life to my home. have hardly any social life because of the pain. Walking have no pain while walking. have some pain while walking but it doesn t increase with distance. cannot walk more than 1 mile without increasing pain. cannot walk more than 1/2 mile without increasing pain. cannot walk more than 1/4 mile without increasing pain. cannot walk at all without increasing pain. Changing degree of pain My pain is rapidly getting better. My pain fluctuates but overall is definitely getting better. My pain seems to be getting better but improvement is slow. My pain is neither getting better or worse. My pain is gradually worsening. My pain is rapidly worsening. ndex Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100 Back ndex Score

4 hysical Health atient Billing Acknowledgement Form Non-Covered Services** Under your health plan, you are financially responsible for co-payments, co-insurance and deductibles for covered services, as well as those services that exceed benefit limits. You are also financially responsible for all non-covered services as defined by your health plan contract. For example, this may include items such as supplies, vitamins, or durable medical equipment. he services or products listed below are not covered according to your health plan. Your acknowledgement below indicates that you have been advised of this information and that you agree to pay for the listed services or products. ** Not for use in New Jersey O V D Services to be provided: Supply DM Modalities/rocedures Other ime frame from through Schedule/details rovider Signature: A N, acknowledge that have been told atient Name rinted or yped in advance by my provider that the services/products listed above are not covered by my Health lan. agree to pay for these non-covered services. atient/guardian Signature ACN_MS-01 evised 10/8/2008

5 hysical Health atient Billing Acknowledgement Form Maintenance/lective Care** Under your health plan, you are financially responsible for co-payments, co-insurance or deductibles for covered services. You are also financially responsible for all non-covered services, including care determined to be elective or maintenance. Maintenance/lective care is treatment that does not significantly improve a clinical condition. While being treated for a chronic condition, you may elect to receive care beyond that which is determined to be medically necessary. You may also choose to receive maintenance care once maximum benefit from treatment has been reached. f, during the course of Maintenance/lective Care, you develop a new condition or a previous condition becomes significantly worse, care may no longer be considered Maintenance/lective and may then be covered by your health plan. Your provider must submit a request for insurance coverage. ** Not for use in New Jersey O V D Services to be provided are listed below: Chiropractic Manipulative herapy n-home Care Modalities/rocedures Other ime frame from through Schedule/details rovider Signature: A N, acknowledge that have been told atient Name rinted or yped in advance by my provider that the services/products listed above are not covered by my Health lan. agree to pay for these non-covered services. atient/guardian Signature ACN_MS-01 evised 10/8/2008

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