AUTHORIZATION FOR AND CONSENT TO NERVE CONDUCTION STUDY OR SPECIAL DIAGNOSTIC PROCEDURES. Consent to Special Diagnostic Procedures

Transcripción

1 AUTHORIZATION FOR AND CONSENT TO NERVE CONDUCTION STUDY OR SPECIAL DIAGNOSTIC PROCEDURES Consent to Special Diagnostic Procedures My signature on this form indicates that: (1) I have read and understood the information provided in this form; (2) I authorize and consent to Precision Occupational Medical Group, Inc. the performance of the procedure(s). 1. I hereby authorize and direct the physicians/surgeons named below to perform the following special diagnostic procedure upon me and to do any other diagnostic procedure and therapeutic procedure that their judgment may dictate to be advisable in case of emergency Doctor: has fully explained to me the nature and purpose of the above mentioned diagnostic or therapeutic procedure and that such diagnostic or therapeutic procedure may involve calculated risks of complications, injury from both know and unknown causes, and no warranty or guarantee has been made as to the results or cure. I recognize that I have a right to be informed of the nature and purpose of the procedure, the expected benefits, the risks of the complications, and the alternative methods of treatment, if applicable. I also recognize that I have the right to be informed whether my physician has any independent medical research or economic interests related to the performance of the proposed operation or procedure. I further recognize that I have the right to consent to or refuse the proposed special diagnostic or therapeutic procedure upon the description or explanation received. Further, I recognize that this form is not intended to be a substitute for the explanations of the nature and purpose of the operation or procedure, the expected benefits, the risks of complication, and the alternative methods of treatment, if applicable, which have been provided by the physician mentioned above. I understand and consent to the performance of the above stated special diagnostic or therapeutic procedure by Doctor(s) and those under his/her immediate responsibility and supervision. 2. I hereby authorize and direct the physician/surgeon named in paragraph 1 above to provide such additional services for me as he/she or they deem reasonable and necessary, including but not limited to, services involving pathology, radiology and I consent there to. Possible risks may include but not limited to bruising, bleeding, infection or muscle pain. I understand, acknowledge and agree that I am financially responsible any portions of the fees for services not paid for by my insurance company, including my deductible, co-insurance and any amount exceeding what my insurance company pays, except where exempt by contractual agreement. I further understand that I am responsible for complying with any requirements that my insurance carrier may have regarding referrals, prior approvals, preauthorizations and second opinions, and that my failure to fully comply with my insurer s requirements may result in the denial of the claim(s) related to the services being provided, and in such instance I am fully responsible to pay. I HAVE READ THE ABOVE WAIVER, AUTHORIZATION AND ACKNOWLEDGEMENT AND/OR IT HAS BEEN FULLY EXPLAINED TO ME, AND I CERTIFY THAT I UNDERSTAND ITS CONTENTS AND THAT I AM COMPETENT TO EXECUTE IT OR THAT I AM AUTHORIZED TO EXECUTE IT ON THE PATIENT'S BEHALF. Patient Signature Date Patient Name

2 PRECISION OCCUPATIONAL MEDICAL GROUP, INC. PERSONAL INJURY QUESTIONNAIRE TODAY S DATE (Fecha De Hoy) PATIENT INFORMATION / Información del Paciente: NAME: Nombre y Apellido: ADDRESS: Dirección: CITY: Ciudad: TELEPHONE NO: No. De Teléfono: BIRTHDATE: Fecha De Nacimiento: DATE OF INJURY (Fecha Del Accidente) STATE (Estado): Male Masculino SOCIAL SECURITY NO (No. De Seguro Social) AGE: Edad: Female Femenino ZIP CODE (Código Postal) AUTO/OTHER INSURANCE INFORMATION (Please provide copy of your auto insurance card) Auto/Otra Información Sobre el Seguro (Porfavor Proveer Copia De Su Tarjeta De Seguro Auto) NAME OF THE COMPANY ( Nombre de La Compania) Policy Number (Numero De Poliza) CLAIM NUMBER (No. De Reclamo) Telephone Number (No De Teléfono) PRIVATE HEALTH INSURANCE INFORMATION (Please provide copy of your private health insurance card) Información Sobre el Seguro De Salud Privado (Porfavor Proveer Copia De Su Tarjeta De Seguro De Salud Privado) NAME OF THE COMPANY ( Nombre de La Compania) GROUP NUMBER (No. De Grupo) PHONE NUMBER (No. De Teléfono) ATTORNEY ATTORNEY NAME (If Applicable)/ Nombre De Su Abogado (Si Aplicable) : ATTORNEY ADDRESS AND PHONE NUMBER / Dirección y No. De Teléfono De Su Abogado EMPLOYER INFORMATION / Información Sobre el Empleador: NAME OF EMPLOYER (Nombre Del Empleador) DATE EMPLOYMENT BEGAN (Fecha de Comienzo) JOB TITLE: Titulo del Trabajo: DESCRIBE HOW THE INJURY/ACCIDENT OCCURRED AND WHAT BODY PART/PARTS WAS/WERE INJURED (Describa que parte del cuerpo se lastimo y como ocurrio) ANY PRIOR HISTORY OF PAIN IN THE INJURED AREA? ( Cualquier historia previa de dolor en la zona lesionada?) YES/Si NO IF YES EXPLAIN(Si respondió si, explicar): DID YOU LOSE CONSCIOUSNESS AS A RESULT OF THIS INJURY? ( Perdió el conocimiento a causa de este accidente?): YES/Si NO Page 1

3 PAST MEDICAL HISTORY (Historia Médica Previa): PRIOR ACCIDENTS/INJURIES? (Accidentes/ Lesiones anteriores?) YES/Si NO DATES/Fechas: IF YES DESCRIBE THE INJURY AND ALL AREAS AFFECTED/AND INDICATE IF YOU HAVE ANY RESIDUAL PAIN/Describa como se lastimo y todas las partes afectadas y explique que areas todavía le duelen: HAVE YOU EVER HAD ANY SURGERIES?/ Ha Tenido Alguna Cirugia Previa? YES/Si NO IF YES, WHEN AND WHAT TYPE / Si Respondio Si, Cuando, Que Tipo CHECK ANY SERIOUS ILLNESSES (CURRENT OR PREVIOUS), SUCH AS/Marque Cualquier Enfermedad Grave Que Tenga O Haya Tenido En El Pasado, Tales Como: ANEMIA ARTHRITIS ASTHMA BLOOD DISORDERS (Asma) (Problemas sanguineos) BRONCHITIS CANCER CHRONIC COUGH CHRONIC HEADACHES (Bronquitis) (Tos crónica) (Dolores de cabeza crónicos) DIABETES DIZZINESS EPILEPSY HEART DISEASE (Diabetis) (Mareos) (Epilepsia) (Probemas cardíacos) HERNIA HIGH BLOOD PRESSURE HIGH CHOLESTEROL KIDNEY DISEASE (Alta presion sanguinea) (Alto cholesterol) (Problemas de riñón) LIVER DISEASE SINUS PROBLEM SKIN RASHES STROKE (Problemas de hígado) (Sinusitis) (Salpullido o erupciones en la piel) (Derrame cerebral) THYROID DISORDER TUBERCULOSIS VISUAL DISTURBANCES WHEEZING (Problemas de tiroides) (Problemas visuals) (Silbido al respirar) OTHER INCONTINENCE OSTEOPOROSIS DEPRESSION (Otra) (Incontinencia) (Depresion) DO YOU HAVE A POSITIVE FAMILY HISTORY FOR ANY OF THE ABOVE? / Tienes Una Historia Familiar Positiva Para Cualquiera De Las Anteriores? YES/Si NO IF YES, PLEASE DESCRIBE/Si respondió si, describes: LIST ANY MEDICATIONS YOU ARE PRESENTLY TAKING/Indique Que Medicamentos Esta Tomando: NAME OF MEDICATION/Nombre de la medicina REASON/Motivo ARE YOU ALLERGIC TO ANY MEDICATION?/ Es Usted Alérgico A Algún Medicamento? YES/Si NO IF YES, EXPLAIN/ Si respondió si, explique DO YOU HAVE ANY ALLERGIES?/ Tiene Algún Tipo De Alergia? YES/Si NO IF YES, WHAT TYPE? / Si Respondió Si,Qué Tipo DO YOU HAVE ANY PSYCHOLOGICAL DISORDERS? / Tiene Usted Algún Problema Psicológico? YES/Si NO IF YES, EXPLAIN/ Si Respondió Si, Explique HAVE YOU EVER HAD AN EMG/NCS TEST IN THE PAST?/ Ha Tenido Alguna EMG/NCS Prueba Previa? YES/Si NO IF YES, WHEN? RESULTS?/ Si Respondió Si, Cuando? Resultados? Page 2

4 LIST YOUR CURRENT COMPLAINTS (INCLUDE FREQUENCY & SEVERITY)/ Describa Su Dolor (Incluya Frequencia E Intensidad Del Dolor). DESCRIBE THE QUALITY OF YOUR PAIN (BURNING, ACHING, STABBING, DEEP, DULL) / Describa El Tipo De Dolor (Quemazón, Punzada, Dolor Ondo, Dolor Leve): DESCRIBE THE SEVERITY OF YOUR PAIN ON A 1-10 SCALE / En Escala Del 1 Al 10, Describa La Severidad De SuDolor: IF YOUR PAIN TRAVELS, WHERE DOES IT RADIATE FROM? / Sí Su Dolor Le Recorre, De Donde Origina? IF YOU HAVE WEAKNESS, NUMBNESS OR TINGLING, PLEASE INDICATE WHERE./ Sí Tiene Debilidad, Adormecimiento Ó Hormigueo, Porfavor Indique En Donde Tiene Esta Sensación: THE PAIN INCREASES WITH/El Dolor Empeora Al: THE PAIN IS RELEIVED BY/El Dolor Se Mejora Al: HOW LONG HAVE YOU HAD THE ABOVE DESCRIBED SYMPTOMS? / Por Cuanto Tiempo A Tenido Los Sintomas Especificados Antereormente? DATE COMPLETED / Fecha SIGNATURE / Firma Page 3

5 Precision Occupational Medical Group, Inc. Corporate Office: 1809 EAST DYER RD, SUITE 313 SANTA ANA, CA TELEPHONE (949) FAX (949) Medical Reports and Doctor s Lien TO: Attorney: Address: Phone: Fax: FOR: Patient Name: DOB: Procedure: I do hereby authorize the above doctor to furnish you, my attorney, with a full report of his examination, diagnoses, treatment, prognosis, etc., of myself in regard to the accident in which I was involved. I agree to direct my attorney to pay my doctor s bills in full for medical service rendered to me. I agree that if my case does not prevail in favor I am financially responsible to pay my doctor s bill before releasing monies directly to me as compensation for pain and suffering. I agree that if my health insurance company does not pay my doctor for treatment, or if the payment is partial, the settlement from my case will be utilized to pay my doctor s bills. I give this lien on my case to my doctor against the proceeds of my settlement, judgment or verdict. I am directly responsible, however, for my bill if my attorney does not protect my doctor s interest with this lien. I understand that when my doctor tells me that I reached a point of maximal medical improvement, it is likely that future treatment will result in medical bills, which may be viewed as excessive by an insurance company thereby reducing monies distributed to me (the patient). Patient Signature: Date: The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect said doctor named above. Attorney s Signature: Date:

6 MDR Network Care, LLC Corporate Office: 1805 E. Dyer Rd, #110, Santa Ana, CA (949) Phone (949) Fax Interpreting Request PATIENT NAME (PLEASE PRINT) DATE OF INJURY DATE OF BIRTH EMPLOYER This is to acknowledge that the patient above has requested an English / Spanish interpreter for office visit today and is not fluent in English. A certified English / Spanish interpreter was not available to assist with today s examination. Therefore a provisional interpreter was used. Esto es para acordar que el/la paciente antereormente mencionado a pedido un interprete de Ingles a Español para su visita de hoy y no habla Ingles. Un interprete certificado de Ingles a Español no estuvo disponible para asistir en su examen de hoy. Por lo tanto un interprete provisional fue usado. Signed by patient: Date:

7 AUTORIZACION Y CONSENTIMIENTO PARA ESTUDIO DE CODUCCION DE LOS NERVIOS MI FIRMA EN ESTE FORMULARIO INDICA QUE: 1) HE LEIDO Y COMPRENDIDO LA INFORMACION PROVEIDA EN ESTE FORMULARIO 2) AUTORIZO Y ESTOY DE ACUERDO A LA REALIZACION, POR PARTE DE PRECISION OCCUPATIONAL MEDICAL GROUP, INC., DE EL ESTUDIO (S) POR LA PRESENTE AUTORIZO A LOS DOCTORES ABAJO NOMBRADO A REALIZAR EL PROCEDIMIENTO ESPECIAL DE DIAGNOSTICO SOBRE MI, Y CUALQUIER OTRO PROCEDIMIENTO TERAPEUTICO QUE SU BUEN CRITERIO INDIQUE RECOMENDABLE EN CASOS DE EMERGENCIA. EL DOCTOR ME HA EXPLICADO EN DETALLE LA NATURALEZA Y PROPOSITO DE ARRIBA MENCIONADO PROCEDIMIENTO DE DIAGNOSTICO ESPECIAL O TERAPEUTICO Y QUE TALES PROCEDIMIENTOS PUEDEN IMPLICAR RIESGOS DE COMPLICACION, LESIONS POR CAUSAS CONOCIDAS O DESCONOCIDAS Y NO SE OFRECE NINGUNA GARANTIA EN CUANTO LOS RESULTADOS O CURA Y RECONOZCO QUE TENGO DERECHO DE ESTAR INFORMADO ACERCA DE LA NATURALEZA Y PROPOSITO DEL PROCEDIMIENTO, LOS BENEFICIOS ESPERADOS, LOS RIESGOS Y COMPLICACIONES Y LOS METODOS ALTERNATIVOS DE TRATAMIENTO, SI FUERA APLICABLE. POSIBLE RIESGOS INCLUYE MORETES, SANGRADOS, INFECCION O DOLOR DE MUSCULOS. TAMBIEN RECONOZCO QUE TENGO EL DERECHO DE SER INFORMADO SI MI DOCTOR ESTA LLEVANDO A CABO ALGUNA INVESTIGACION MEDICA INDEPENDIENTE O INTERES ECONOMICO RELACIONADOS CON EL RENDIMIENTO DE LA OPERACION O EL PROCEDIMIENTO PROPUESTOS. RECONOZCO ADEMAS QUE TENGO EL DERECHO DE APROBAR O REHUSAR EL PROPUESTO DIAGNOSTICO ESPECIAL O TERAPEUTICO EN LA DESCRIPCION Y EXPLICACION RECIBIDAS. TAMBIEN RECONOZCO QUE ESTE FORMULARIO NO INTENTA SER SUBSTITUIDO POR LAS EXPLICACIONES DE LA NATURALEZA Y EL PROPOSITO DEL PROCEDIMIENTO, LOS BENEFICIOS ESPERADOS, LOS RIESGOS DE COMPLICACION, Y LOS METODOS ALTERNATIVOS DE TRATAMIENTO SI FUERAN APLICABLES, LOS CUALES ME HAN SIDO PROPORCIONADOS POR EL MEDICO ARRIBA NOMBRADO. YO COMPRENDO Y DOY MI CONSENTIMIENTO PARA QUE EL DOCTOR/ES LLEVE A CABO EL ARRIBA NOMBRADO PROCEDIMIENTO O DIAGNOSTICO ESPECIAL O TERAPEUTICO, Y PARA AQUELLAS PERSONAS QUE ESTEN BAJO SU INMEDIATA RESPONSABILIDAD Y SUPERVISION. YO AUTORIZO A LOS MEDICOS Y CIRUJNAOS NOMBRADOS EN EL PARRAFO 2 A PROVEERME CON LOS SERVICIOS ADICIONALES QUE ELLOS CREAN CONVENIENTES Y NECESARIOS, INCLUYENDO PERO NO LIMITADO, LA ADMINISTRACION DE ANESTESIA Y SERVICIOS RELACIONADOS CON PATOLOGIA Y RADIOLOGIA Y DOY MI CONCENTIMIENTO. ENTIENDO Y ESTOY DE ACUERDO QUE SOY ECONOMICAMENTE RESPONSABLE POR CUALQUIER PORCION DEL COSTO POR LOS SERVICIOS NO PAGADOS POR MI COMPANIA DE SEGURO, INCLUYENDO EL DEDUCTIBLE, CO-PAGO Y CUALQUIER CANTIDAD QUE EXCEDA LO QUE MI COMPANIA DE SEGURO PAGUE EXCEPTO DONDE ESTE EXEMPTO POR UN CONTRATO. ENTIENDO QUE SOY RESPONSABLE POR CUMPLIR CON LOS REQUISITOS QUE MI COMPANIA DE SEGURO TENGA, REFERENCIAS, AUTORIZACIONES PREVIAS, PRE AUTORIZACIONES Y SEGUNDAS OPINIONES Y QUE AL FALLAR O NO CUMPLIR PLENAMENTE CON LOS REQUISITOS DE LA COMPANIA DE SEGURO PUEDE RESULTAR EN NEGACION DEL RECLAMO RELACIONADO CON LOS SERVICIOS OTORGADOS, EN ESE CASO SOY TOTALMENTE RESPONSABLE DEL PAGO POR LOS SERVICIOS. HE LEIDO LA RENUNCIA VOLUNTARIA, AUTORIZACION Y ADMICION Y HA SIDO PLENAMENTE EXPLICADO Y CERTIFICO QUE ENTIENDO EL CONTENIDO Y QUE SOY COMPETENTE PARA EJECUTARLO O QUE ESTOY AUTORIZADO PARA EJECUTARLO A NOMBRE DEL PACIENTE. NOMBRE/FIRMA DEL PACIENTE FECHA IMPRIMIR/NOMBRE