david e. teitelbaum, d.o., p.a
TRANSCRIPT
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DAVID E. TEITELBAUM, D.O., P.A. Acupuncture Prolotherapy Osteopathic Manipulation
4455 Camp Bowie Blvd #214 Phone: (817) 335-4220 Fort Worth, Texas 76107 Fax: (817) 335-3171 Name: _________________________________________ Phone(s):________________________________
Phone at which you would like to receive appointment reminders: ___________________
Address: _______________________________________ City: _____________ State: _____ Zip: _______ Date of Birth: ___________ Age: _____ SS#: ___________________ Driver’s Lic #: _________________ Who referred you? _________________________ Family Physician: ______________________________ Sex: M / F Marital Status: S M D W Do you have Medicare? Y / N Occupation: _____________________________ Employer Name: _________________________________ Address: _______________________________________ City: _____________ State: _____ Zip: _______ Work phone: ____________________ Emergency Contact: __________________________________________ Phone: ______________________ Responsible Party for Billing: __________________________________ Phone: ______________________ Address: ________________________________________ City: ____________ State: ______ Zip: ______ If insurance is in your spouse’s name: Name: __________________________________________________ SS#: _________________________ Work phone and address:____________________________________ Dr. Teitelbaum often has medical students training under him. If you would prefer not to have a medical student present during your visit, please check here: ___________
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I hereby authorize David E. Teitelbaum, D.O. to release any information acquired in the course of my examination and treatment. I hereby authorize any physician, hospital or medical care facility to provide all information on my medical history and treatment to include xray reports or films to David E. Teitelbaum, D.O. I hereby authorize David E. Teitelbaum, D.O. to receive the payment directly for the surgical and medical benefits, if any, otherwise payable under the terms of my insurance contract/policy. I herby authorize photocopies of this form to be as valid as the originals. _________________________________________________ _______________________ Patient Signature Date _________________________________________________ _______________________ Authorized Signature Date
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DAVID E. TEITELBAUM, D.O., P.A.
Acupuncture Prolotherapy Osteopathic Manipulation 4455 Camp Bowie Blvd #214 Phone: (817) 335-4220 Fort Worth, Texas 76107 Fax: (817) 335-3171 ____________________________________________________________________________________________________________________________________________________________________________________________________ Welcome to our practice! Please answer all of the following questions to help us serve you more efficiently. NAME: ____________________________________________ DATE: ______________________________ Please describe each of your main complaints. Include date of onset and what has happened since that time. (Continue on the back of this page if needed.) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________ If any of your main complaints are work related, auto accident related or injury related, please describe in detail how the accident happened, giving dates, times and events. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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Please list any treatments (including home remedies) and surgeries that you have tried so far. Indicate if they have helped, had no effect on, or worsened your condition. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Describe any disability that has resulted from your main complaints relative to your work, social life, home life or leisure activities. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you had Xrays, MRI, etc.? Yes / No When? ____________________Where?__________________________________ Please list all medications you are currently taking and the reasons for taking them. Include vitamins, aspirin, Tylenol, birth control, laxatives, antacids, etc. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please list all allergies: _______________________________________________ __________________________________________________________ Please list all surgeries with dates: _________________________________________________________________________________________________________________________________________________________________________________________________________
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Describe any other serious illnesses you have had in the past 2 years not already listed with your main complaints: ____________________________________________________________________________________________________________________ Do you have any worries (legal, financial, personal) that might be affecting your health? __________________________________________________________________ Do you have a source of spiritual strength that you turn to in times of trouble? __________________________________________________________________ Do you exercise regularly? Yes / No How? How often? __________________________________________________________________ Do you sleep well? Yes / No Do you awaken refreshed? Yes / No Do you have a history of drug, alcohol, or substance abuse? Yes / No Describe: __________________________________________________________ Do you drink alcoholic beverages? Yes / No Amount per week: ___________ Number of sodas per week: Diet ____ Regular ____ Do you now, or have you ever smoked? Yes / No How many years? ________
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After careful consideration, please check all of the following that apply to you: I. Symptoms:__ Eye or vision problems __ Sensitive to bright light, sound, wind, odors __ Tension or pain in shoulders, neck, and upper back
__ Nervous, irritable, short tempered __ Headaches __ Migraines __ Weak or brittle nails
__ Difficulty sleeping __ Cold hands and feet
Traits: __ Feel confident, act assertively __ Ambitious and enjoy being competitive __ Openly discuss my abilities and achievements __ Comfortable with challenges, conflict or pressure
__ Enjoy being first, best, unique, even outlandish __ Comfortable directing or leading others __ Follow my own hunches __ Feel right, even if others disagree or disapprove
II. Symptoms: __ Anxiety, nervousness, or dread __ Sensitive to heat and cold __ Hot flashes
__ Restless and excitable __ Crave cool drinks and spicy foods __ Sores of mouth and tongue
__ Easy blushing __ Burning sensations __ Heart or circulation problems
Traits: __ Enjoy the pleasure my senses __ Easily know what another thinks and feels __ Enjoy physical contact and emotional intimacy __ Enjoy excitement and stimulation __ Easily share my innermost feelings and desires
__ Get involved easily, enjoy being moved emotionally __ Optimistic and hopeful despite what others may say __ Easily show affection, enthusiasm and excitement
III. Symptoms: __ Difficult bowel movements __ Slow digestion or indigestion __ Loose stool or diarrhea __ Frequent gas or bloating
__ Water retention, puffiness __ Difficulty focusing, distractible __ Irritable Bowel
__ Ulcers __ Sensation of heaviness in the head, body, and limbs
Traits: __ Agreeable and accommodating __ Nurturing and supportive, putting others needs first __ Enjoy frequent socializing with friends and family __ Enjoy being relied upon for reassurance and help
__ Involved in other people’s lives __ Like to create a comfortable environment for others __ Loyal and accessible to friends, family, and co-workers __ Like getting close and being needed
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IV. Symptoms: __ Coughing, sneezing __ Respiratory allergies __ Runny nose or stuffy sinuses __ Frequent or lingering colds, coughs, sore throat __ Thyroid problems
__ Frequent phlegm __ Shortness of breath or wheezing from exertion __ Asthma __ Bronchitis
__ Dryness or tightness of mucous membranes or skin __ Skin rashes, eczema, or hives __ Skin growths, acne
Traits: __ Prefer a neat and orderly lifestyle __ Committed to high moral principles and conduct __ Meticulous, tasteful and discriminating __ Self-contained, not overly involved in others’ affairs
__ Willing to accept the authority of those with more competence __ Enjoy solving puzzles and mysteries __ Virtue and principle before pleasure and fulfillment __ Like things to run calmly and smoothly
V. Symptoms: __ Ear or hearing problems __ Dark rings under eyes __ Diminished libido __ Frequent or difficult urination
__ Kidney or bladder problems, infections __ Stiffness of spine and joints __ Recurring low back pain __ Hair loss or premature graying
__ Lack of stamina and endurance __ Need to sleep a lot __ Apathy, low motivation __ Mental dullness
Traits: __ Cautious and sensible __ Particularly enjoy solitude __ Tend to keep feelings, thoughts and opinions to myself __ Don’t mind being considered unusual or eccentric
__ Excited by intellectual pursuits __ Careful about what I reveal to other people __ Preferably self-sufficient and independent __ Cherishing privacy and a few good friends
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DAVID E. TEITELBAUM, D.O., P.A.
Osteopathic Manipulation Acupuncture Prolotherapy
4455 Camp Bowie Blvd #214 Phone: (817) 335-4220 Fort Worth, Texas 76107 Fax: (817) 335-3171
OUR OFFICE POLICIES
Please complete and sign all of our forms and bring them with you to your appointment. We would appreciate your arrival 20 minutes prior to your appointment to give us sufficient time to process all of your information. INSURANCE: NOTE: Our office does not file insurance on group or private plans. We do, however, provide you with a superbill which you may use to file for reimbursement with your insurance carrier. NOTE: We do accept and file Medicare claims and Medicare secondary insurances only. Remember to bring your Medicare card and your Medicare supplemental insurance cards. If you have Medicare, it is your responsibility to pay for any deductible amount, co-insurance, non-covered services, or any other balance not paid by your insurance company. To keep our fees as low as possible, it is our policy to collect for services at the end of each appointment, unless you have Medicare. For your convenience, we accept payment by Mastercard, Visa, and Discover, American Express and personal checks. We do not accept post-dated checks. Medical insurance usually reimburses well for office visits and Osteopathic manipulative treatments. Reimbursement for Acupuncture, Prolotherapy, and Spinal Decompression varies widely. MISSED APPOINTMENTS: Please recognize that an appointment cancelled at the last minute results in a lost opportunity for another patient to see us. We therefore require 24 hours advanced notice for cancellation. Patients who do not cancel an appointment 24 hours in advance will be billed for the entire amount of that appointment. Exceptions will be made for emergency situations. I have read the above and understand Dr. Teitelbaum’s office policies. Signed: ____________________________________ Date: _________________
DAVID E. TEITELBAUM, D.O., P.A. Osteopathic Manipulation Acupuncture Prolotherapy
4455 Camp Bowie Blvd #214 Phone: (817) 335-4220 Fort Worth, Texas 76107 Fax: (817) 335-3171
NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get a copy of your medical record
• You can ask to see a copy of your medical record and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a
reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. • We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to
200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information, simply tell us what you want us to do, and we will follow your instructions.
How do we typically use or share your health information? We rarely need to share a patient’s health information, but these are some situations that may arise:
In Treatment: We can use your health information and share it with other professionals who are treating you.
In billing for your services: We can use and share your health information to bill and get payment from health plans or other entities.
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. Some of these situations include: preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect, or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety.
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Examples include: workers’ compensation claims, law enforcement purposes or with a law enforcement official, health oversight agencies for activities authorized by law, or special government functions such as military, national security, and presidential protective services. We can share health information about you in response to a court or administrative order, or in response to a subpoena.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Our Responsibilities: We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
This notice is effective: 10-20-2017. If you have any questions related to this policy or its implementation, contact our Privacy Official: David E. Teitelbaum, D.O., at the number or Email above.
I have read this privacy notice for the office of David Teitelbaum, D.O.
Signed: __________________________________________________ Date: __________________________________