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    William F. Sima, M.D., Inc.

    322 Posada Lane, Suite A ~ Templeton, Ca 93465
    Phone: 805.434.5555 ~ Fax: 805.434.5502

    Thank you for scheduling an appointment with my office. I look forward to evaluating your orthopaedic condition.

    Please complete this packet PRIOR to your appointment on:

    TO AVOID RESCHEDULING: PLEASE arrive 15 minutes prior to your scheduled appointment and bring:

    • ALL COMPLETED FORMS

    • CURRENT INSURANCE CARD(S)

    • PICTURE ID

    ORIGIN OF PAIN

    This information is required by all insurance Companies. Under the provisions of the contract with your private insurance for you and your dependent (s), liability may be an exclusion of your policy. So that your private insurance company can determine if they are correct in accepting liability for the services provided for this problem/injury, they will need the following information:

    BODY PART FOR THIS VISIT:

    Is injury due to an automobile accident, liability accident or Workman’s Compensation?

    If yes, please provide the following information:

    Nature of accident:

    Date of accident:

    Claim Number:

    Claims address (Auto/Work Comp/Liability):

    MEDICARE COVERAGE

    FAILURE TO DISCLOSE ALL INSURANCE PLANS CAN CAUSE DENIAL/DELAY OF CLAIM PAYMENT! Medicare requires that providers determine whether Medicare is the primary or secondary payer for each claim for a Medicare beneficiary. The MSP form is used as a guide during the registration process to help identify other payers which may be primary to Medicare.

    DO YOU HAVE MEDICARE COVERAGE?

    If NO & and over 65 please explain why you do NOT have Medicare:

    If YES & under 65

    Is your Medicare coverage due to disability?

    Are you covered by a large Employer Group Health Plan (20 or more employees) based on your own or spouse’s current employer? If yes, Medicare is secondary and primary information must be obtained

    If YES & Over 65,

    Are you covered by Employer Group Health Plan based on your own or spouse’s current employer? If yes, Medicare is secondary and primary information must be obtained

    I CERTIFY THE ABOVE STATEMENTS TO BE TRUE TO THE BEST OF MY KNOWLEDGE

    Signature (Patient/Responsible Party)

    NAME (And Relationship if not the patient)

    DATE

    William F. Sima, M.D., Inc.

    322 Posada Lane, Suite A ~ Templeton, Ca 93465
    Phone: 805.434.5555 ~ Fax: 805.434.5502

    PATIENT INFORMATION

    GUARANTOR (Or person responsible for bill if different from above)

    PRIMARY INSURANCE

    DATE OF BIRTH:

    SECONDARY INSURANCE (IF APPLICABLE)

    DATE OF BIRTH:

    • am responsible for payment due at time of service (ie: co-pay, co-ins, ded, non-covered/denied services, and/or cash pay)

    • 1.5% per month (18% per yr) interest charge and/or late fee may be added to unpaid balances over 30 days.

    • $25.00 non-sufficient funds (NSF) fee will be charged for all returned checks.

    • $50.00 may be charged for appointment cancelled or missed without 24 hours’ notice.

    • $15.00 minimum charge may be charged for completion of forms

    • $15.00 may be charged for providing inaccurate, outdated, and/or incomplete insurance information that result in additional billing.

    • There may be a charge for copying medical records.

    • I authorize payment of medical benefits to William F. Sima, MD for services provided.

    Signature (Patient/Responsible Party)

    Name and Relationship if not the patient

    DATE

    William F. Sima, M.D., Inc.

    Orthopaedic Surgery, Sports Medicine and Joint Replacement

    Date of Birth:

    AUTHORIZATION TO RELEASE / OBTAIN INFORMATION

    I hereby authorize William Sima, M.D. to obtain any and all medical records pertinent to my care from any physician, hospital, or other health care professional.

    I also hereby authorize William Sima, M.D. to release any medical records belonging to them concerning my care to any physician, hospital, or other health care professional. These may include but not be limited to mental health records protected by Lanterman Pertis Short Act, drug and alcohol abuse records and HIV test results to any except as specifically

    follows:

    This authorization is effective now and will be in effect for the time that I am a patient of William Sima, M.D., or until I revoke it in writing.

    William Sima, M.D. reserves the right to modify the privacy practices outlined in the notice.

    RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM

    A copy of the HIPPA guidelines for the office of William Sima, M.D. was made available to me to read at the front desk. Upon request a copy can be made. I understand that due to these guidelines, medical information will only be discussed with me and those listed below. Medical information may include but is not limited to appointments, prescriptions, test results and chart notes.

    Date of Birth:

    Date of Birth:

    Date of Birth:

    Signature (Patient/Responsible Party)

    Name and Relationship if not the patient

    DATE

    An attempt was made to obtain an acknowledgement of receipt of the “Notice of Privacy Practices” but was not obtained because:

    CONSENT TO PHOTOGRAPH/VIDEOTAPE/FILM/INTERVIEW INDIVIDUALS

    I give William Sima, M.D., Inc. permission to photograph, videotape, film and/or interview myself, and to publish said photographs, videotapes, films, written testimonials and/or interviews on the internet, Dr. Sima’s web site and all other forms of media. The photographs, videotapes, etc. shall constitute the exclusive property of William Sima, M.D., Inc. and may be reproduced by William Sima, M.D., Inc., without compensation or payment to the individual concerned or any other person. I also hereby release William Sima, M.D., Inc. and his employees from all claims, demands, and liabilities whatsoever in connection with the above.

    Signature (Patient/Responsible Party)

    Name and Relationship if not the patient

    DATE

    William F. Sima, M.D., Inc.

    322 Posada Lane, Suite A ~ Templeton, Ca 93465
    Phone: 805.434.5555 ~ Fax: 805.434.5502

    Date of Birth:

    MEDICAL HISTORY

    MEDICATION ALLERGIES

    CHECK HERE IF NO KNOWN MEDICATION ALLERGIES

    1.

    2.

    3.

    4.

    5.

    6.

    CURRENT MEDICATIONS

    CHECK HERE IF NO CURRENT MEDICATIONS

    FAMILY MEDICAL HISTORY

    CHECK HERE IF NONE APPLY

    Do any of your grandparents, parents, siblings or children have the following diseases?

    Anemia:

    Hypertension:

    Asthma:

    Kidney Disease:

    Autoimmune Disorder:

    Liver Problems:

    Bleeding Disorder:

    Lung Problems:

    Osteoporosis:

    Cardiovascular:

    Rheumatoid Arthritis:

    Deep Venous Thrombosis :

    Seizures:

    Diabetes:

    Stroke:

    Heart Problems:

    Thyroid Disease:

    William F. Sima, M.D., Inc.

    Orthopaedic Surgery, Sports Medicine and Joint Replacement

    PAST MEDICAL HISTORY

    CHECK HERE IF NONE APPLY

    REVIEW OF SYSTEMS

    CHECK HERE IF NONE APPLY

    SURGICAL HISTORY

    CHECK HERE IF NO PRIOR SURGERIES

    SURGERY:

    DATE:

    SIDE:

    SURGERY:

    DATE:

    SIDE:

    SURGERY:

    DATE:

    SIDE:

    SURGERY:

    DATE:

    SIDE:

    SURGERY:

    DATE:

    SIDE:

    SURGERY:

    DATE:

    SIDE:

    Did you have any complications with surgeries or anesthesia?

    Shoulder Evaluation
    William F. Sima, M.D.

    Date of Birth:

    Which shoulder are you being seen for today?

    Are you:

    Your first symptoms began:

    As a result of:

    Previous Treatment:

    I have not received any treatment for this condition

    Current Symptoms:

    Quality of Pain:

    Pain Radiates to:

    Pain is worse with:

    Weakness:

    Paresthesias (Tingling):

    Also Experiencing:

    Instability:

    Stiffness:

    Work Status:

    Pain

    What amount of shoulder pain have you experienced in the last week doing the following:

    1. Reaching overhead:

    2. Reaching behind back:

    3. Lifting:

    FUNCTION (daily living):

    4. Showering and personal hygiene:

    5. Putting on shirt:

    6. Getting in and out of chair:

    William F. Sima, M.D., Inc.

    Orthopedic Surgery, Sports Medicine and Joint Replacement

    Date:

    MEDICAL HISTORY

    Previous Tests and Treatments

    Check here if none apply:

    Physical Therapy:

    Anti-inflammatories:

    Narcotic medication:

    Chiropractic/Manipulation:

    Epidural steroid injection:

    Steroid injection:

    X-rays:

    CT:

    MRI :

    Current Medication(s):

    Check here if none:

    Do you have any ALLERGIES?

    Social History (check all that apply to you)

    Drink alcohol?

    Employment?

    Disabled?

    Exercise?

    Marital Status?

    Smoking?

    Quit smoking?

    Date:

    Family History

    Do any of your grandparents, parents, siblings or children have the following diseases?

    Anemia:

    Asthma:

    Autoimmune disorder:

    Bleeding disorder:

    Cardiovascular:

    Deep Venous Thrombosis:

    Diabetes:

    Hypertension:

    Kidney Disease:

    Liver problems:

    Lung problems:

    Rheumatoid arthritis:

    Seizures:

    Stroke:

    Thyroid disease:

    Past Medical History (circle all that apply to you)

    CHECK HERE IF NONE APPLY

    Dermatologic:

    lupus / melanoma / skin cancer

    Neurological:

    epilepsy / seizure disorders / stroke

    Renal / Urinary:

    hematuria / kidney problems / incontinence

    Endocrine:

    diabetes / thyroid disorder

    Head and Neck:

    Dentures / migraines / glaucoma

    Genetic Background:

    congenital heart defect / hemophilia / sickle cell

    Childhood Illnesses:

    polio / asthma

    Female Reproductive:

    cancer / tumors

    Male Reproductive:

    BPH / prostate conditions

    Gastrointestinal:

    Crohn’s disease / gastritis / GI bleed / irritable bowel syndrome / ulcer

    Respiratory:

    asthma / bronchitis / emphysema / pulmonary embolism / shortness of breath / tuberculosis / COPD

    Musculoskeletal:

    ankylosing spondylarthritis / arthritis conditions / fibromyalgia / osteoporosis / polio / Rheumatoid arthritis

    Cardiovascular:

    cardiac catheterization / cardiac disease / congestive heart failure / deep vein thrombosis / edema / heart valve conditions / myocardial infarction / stroke / hypertension / Atrial fibrillation

    Hematologic/lymphatic:

    anemia / bleeding tendencies / hemophilia / hepatitis

    Psychiatric:

    alcoholism / depression

    All Previous Surgeries

    CHECK HERE IF NO HISTORY OF PRIOR SURGERY

    1. Date

    Type

    2. Date

    Type

    3. Date

    Type

    4. Date

    Type

    5. Date

    Type

    6. Date

    Type

    Did you have any complications with your surgeries or anesthesia?

    Date:

    Review of Systems (circle all that apply to you)

    CHECK HERE IF NONE APPLY

    Allergic/ Immunologic:

    Seasonal Allergies

    Cardiovascular:

    Elevated blood pressure / Heart attack / Heart palpations / Pacemaker / Atrial fibrillation / Heart valve replacement

    Constitutional Symptoms:

    Chills / Fever / Nausea

    Ears, Nose, Mouth, Throat:

    Difficulty with hearing / Cough / Difficulty with swallowing / Loss of hearing

    Endocrine:

    Dry skin / Unusual fatigue / Weight change / Thyroid disease

    Eyes:

    Eye or vision problems / Glasses / Loss of vision

    Gastrointestinal:

    Blood in stool / Diarrhea / Hemorrhoids / Stomach ulcers / GERD

    Genitourinary:

    Blood in urine / Painful urination / Incontinence

    Hematologic/ Lymphatic:

    Anemia / Bleeding problems / Bruise easily

    Integumentary:

    Non healing wound / Rash

    Musculoskeletal:

    Back pain / Difficulty getting out of a chair

    Neurological:

    Balance problems / Difficulty walking / Headaches / Migraines / Seizures / Stroke

    Psychiatric:

    Depression / Anxiety

    Respiratory:

    Asthma / Chest pain / Shortness of breath / Sleep apnea

    NOTICE OF PRIVACY PRACTICES

    (MEDICAL)
    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

    The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, penalties for covered entities that misuse personal health information.

    As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

    We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations.

    • Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.

    • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.

    • Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

    We may also create and distribute de-identified health information by removing all references to individually identifiable information.

    We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

    Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

    You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

    • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

    • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.

    • The right to inspect and copy your protected health information.

    • The right to amend your protected health information.

    • The right to receive an accounting of disclosures of protected health information.

    • The right to obtain a paper copy of this notice from us upon request.

    We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

    This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

    You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

    For more information or to file a complaint, please contact:


    The U.S. Department of Health & Human Services

    Office of Civil Rights

    200 Independence Avenue, S.W.

    Washington, D.C. 20201

    (202) 819-0257, Toll Free: 1-877-696-6775

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