Regenerative Orthopedics and Sports Medicine
Victor M. Ibrahim, MD, John Ferrell, MD, David C. Wang, D.O.
REGISTRATION FORM
Patient Name: ______________________________ Date:____________________________
Age:___________
Date of Birth:__________________
Gender: M / F
Address: _________________________City:_____________________ State: ___Zip:_____
Home Phone:_________________
Work Phone: _________________
Cell Phone: _________________ _
Email Address:__________________
Emergency Contact:_____________________Relationship:____________
Phone:__________________Legal Guardian (if under 18): _____________
ROSM is an Out of Network Provider, but may assist with insurance reimbursement.
All payments are due at the time of treatment.
Primary Insurance: __________________________ Policy #___________________
Insurance Policy holder (name):______________________________
Relationship to Patient:_______________________ Date of Birth:_______________
Address (if different from above)______________________________________________
Assignment and Release of Information statement: I certify that the information given by me is correct. I understand that
this information is entered into a database and I hereby authorize the release of information related to my medical care as
requested by government agencies and/or insurance carriers. I hereby assign benefits and understand that in the absence of
accepted insurance coverage, I/Legal guardian am responsible for full payment of services rendered. Litigation Disclaimer: It
is understood and agreed that I am requesting examination and treatment for medical purposes only, and not requesting any
information in connection with pending or proposed litigation.
Authorized Signature/Guardian:____________________________________Date:____________
Regenerative Orthopedics and Sports Medicine
Victor M. Ibrahim, MD, John Ferrell, MD, David Wang, D.O.
REGISTRATION FORM
Name_________________________________________Age______Birthdate______________
Chief Complaint:______________________________________________________________
Date of injury or symptom onset:__________________________________________________
Please describe the injury or
problem:______________________________________________
Where is your pain? Please mark the
drawing
0 = No
pain 10 = Extreme pain
Please
indicate your pain level
1. Right now 0 1 2 3 4 5 6 7 8 9 10
2. At best 0 1 2 3 4 5 6 7 8 9 10
3. At worst 0 1 2 3 4 5 6 7 8 9 10
4. What makes it better?_______________
5. What makes it worse?_______________
Circle the words which best describe your symptoms:
Dull/Ache
Shooting
Awareness
Sharp/Stabbing Gnawing
Burning
Numbness
Throbbing
Heaviness
Weakness
Tightening/Constricting
What diagnostic tests have you had for this condition? (X-ray, MRI, EMG, etc.)
Diagnostic test
Date
Results
Please list all treatments that you have tried for you condition including physical/occupational therapy,
massage, acupuncture chiropractic, injections, and medications (please list type of injection and/or
medications). Circle which treatments have helped you the most.
Past Medical History
Please list any ongoing medical problems (High blood pressure, Diabetes, Thyroid disorder, Cancer,
Bleeding disorder, Heart disorder, Asthma, Arthritis, Headaches)
Past Surgical History(Procedure, Date)
Current Medications, Vitamins, or Nutritional Supplements
Medication
Dosage
Frequency
Are you allergic to any medication? Y N If yes, please list.
Family History
Does anyone in your family have any of the following problems?
Heart disease High blood pressure Cancer Nerve Disorders Stroke Diabetes
Blood problems
Other____________________________
Symptom Review (circle symptoms you have experienced in the past week)
Chest Pain
Leg Swelling Numbness
Excess Sweating Breathing Difficulty Digestive
Symptoms
Tingling
Hair Loss
Visual Changes
Rash
Weakness
Bruising
Hearing Loss Urinary Symptoms Excess Thirst
Excess bleeding Nervousness
Sinus Congestion
Joint Stiffness
Mood Changes
Other/Explanation:___________________________________________________
Please provide Physician information
Primary Care Physician
Name:
Phone:
Fax:
Referring Provider
Name:
Phone:
Fax:
What is your occupation or former occupation? Are you retired or disabled?
Are you single, married, partner, divorced, or a widow/widower?
What type of physical activity do you do and for how many hours per week?
Do you smoke, drink alcohol, or use illegal substances? If yes, how often?
Do you consider your current weight ideal? Y N If not, what is your ideal weight?
Do you have any questions about healthy ways to control your weight?
What are your goals or expectations from our treatment?
What specific issues would you like addressed today?
The information I have provided is accurate and complete to the best of my knowledge:
Signature:____________________________________ Date:__________________
Regenerative Orthopedics and Sports Medicine
Victor M. Ibrahim, MD, John Ferrell, MD, David Wang, D.O.
WORKER’S COMPENSATION/PERSONAL INJURY CLAIM
Last Name:_________________________ First
Name:_________________________________
Address:______________________________City:__________________State:______
Zip:_____
Sex:____________SS#:__________________________D.O.B._________________________
_
Telephone: (H)_____________________(W)__________________
(C)____________________
Emergency contact:___________________________
Relation:___________________________
X-rays within 3-6
months:__________Location:________________________________________
Workers Compensation Information:
Case Manager:____________________________________ Phone:______________________
Insurance Carrier:__________________________________ Claim #:_____________________
Address:______________________________City:__________________State:______Zip:____
_
Date of injury:______________ Address where injury
occurred:___________________________
City:_________________________ State:________ Zip:________
Time:___________________
No Fault Insurance Information
Name of Vehicle Ins.
Company:____________________________________________________
Address:______________________________City:__________________State:______Zip:____
_
Name of Adjuster:_______________________________
Phone:__________________________
Policy #:______________________________________ Claim
#:_________________________
Date of Accident:_______________________________
Injury:___________________________
Regenerative Orthopedics and Sports Medicine
Victor M. Ibrahim, MD, John Ferrell, MD, David Wang, D.O.
CONSENT FORM
I, ___________________________________ understand that as part of my health care, ROSM
will create and maintain a health records describing my health history, symptoms, examinations
and test results,diagnosis, treatment, and any plans for future care or treatment.
I understand that this information serves as a:
• Mode of communication among the many health professionals who contribute to my care;
• Source of information for applying my diagnosis information to my bill;
• Basis for planning my care and treatment;
• Means by which a third-party payer can verify that services reported were actually provided
• A tool for routine healthcare operations such as assessing the quality and reviewing the
competence of healthcare professionals
• Anonymous data may be used to track clinical progress to use for research purposes
I understand that I am entitled to a more complete description of this information uses and
disclosures. I understand the organization reserves the right to change their notice and
practices prior to implementation will mail a copy of any revised notice to the address above that
I've provided. I understand that I have the right to object to the use of health information for
directory purposes. I understand that I have the right to request restrictions as to how my health
information may be used or disclosed to carry out treatment,payment, or healthcare operations
and that the organization is not required to agree to the restrictions requested. I understand that
I may revoke this consent in writing, except to the extent that the organization has already taken
action in reliance thereon.
I also fully endorse responsibility for all fees related to my care. I understand that my insurance
provider may or may not reimburse me for these services, and I will remain wholly responsible
for payment.
I fully understand and accept the terms of this consent.
Signature:________________________________________ Date:______________
Regenerative Orthopedics and Sports Medicine
Victor M. Ibrahim, MD, John Ferrell, MD, David Wang, D.O.
REGISTRATION FORM
PAYMENT RESPONSABILITY
I understand that I have a personal and primary obligation to pay for all medical services when
rendered and I agree to pay all bills promptly. I further understand that although ROSM may
submit a bill to my insurance company for payments as a service to me, that service does not
relieve me of my personal responsibility to ensure that the insurance company makes payment
according to the terms of my policy. I am aware that insurance payment/reimbursement may not
cover the total balance due for the medical services I received. I agree to pay any outstanding
on my account, if such action is deemed necessary. In addition, I agree to pay interest ($5.00
per service) on my outstanding account balance if this balance extends beyond thirty (30) days
of receipt of my bill. I agree to pay any additional fees and/or costs incurred in order to collect
payments on my account(s).
Patient/Responsible party signature:
__________________________________Date:_________
INSURANCE AUTHORIZATION
AUTHORIZATION OF ASSIGNMENT:
I hereby authorize ROSM to apply for benefits from my insurance company on my behalf for
covered services by ROSM. Finally, I authorize the release of any medical or other information
necessary to process claims submitted to my insurance company.
Patient/Responsible party signature:
__________________________________Date:_________
AUTHORIZATION OF PAYMENT:
I authorize payment to be made directly to ROSM.
Patient/Responsible party signature:
___________________________________Date:________
Regenerative Orthopedics and Sports Medicine
Victor M. Ibrahim, MD, John Ferrell, MD, David Wang, D.O.
REGISTRATION FROM
MEDICARE INSURANCE ONLY
I HEREBY AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO
THE HEALTH CARE FINANCING ADMINISTRATION AND ITS AGENTS, ANY INFORMATION
NEEDED TO DETERMINE THE BENEFITS PAYABLE FOR RELATED SERVICES. I ALSO AUTHORIZE
M.O.S.T AND DR.S’ GILBERT & OMOHUNDRO P.A. TO INVESTIGATE THE NON-PAID STATUS OF
MY ACCOUNT WITH MEDICARE.
Patient/Responsible party signature: ___________________________________ Date: _____________
Please be advised that we have found that most insurance carriers have limited or no benefits
for durable medical equipment (slings, braces, orthotics, etc). Therefore we must collect from
you the fee for the equipment at the time of service. Custom made braces are partially covered
by some insurance carriers. At the time of measuring you for the custom made brace, we will
contact your insurance carrier to verify coverage and give you an estimate of your responsibility.
Thank you for your cooperation. X_____________________ (Please Initial)
Cancellation/Late Policy
Please be aware that proper scheduling requires each patient to be on-time for their
appointment. If the patient is more than 15 minutes late, the provider may exercise the right to
refuse treatment for that appointment. The ROSM cancellation policy requires that the patient
call at least 24 hours in advance of the appointment time. A fee of $ 25.00 will be applied if
proper notice is not given.
Patient/Responsible party signature _________________ Date ____/____/____
Victor Ibrahim, MD, John Ferrell, MD, David Wang, D.O.
600 Pennsylvania Ave SE. #202
Washington, DC 20003
Private Contract
This agreement is between Victor Ibrahim, MD, John Ferrell, MD, OR David Wang, DO for
services provided at 600 Pennsylvania Ave SE. #202 Washington, DC 20003
Beneficiary: _______________________________
Who resides at: ____________________________
Medicare ID #: _____________________________
and is a Medicare Part B beneficiary seeking services covered under
Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of
1997. The Physician has informed Beneficiary or his/her legal representative
that Physician has opted out of the Medicare program effective on August 1,
2012 for a period of at least two years, to expire on July 31, 2014. The
physician is not excluded from participating in Medicare Part B under
[1128] 1128, [1156] 1156, or [1892] 1892 of the Social Security Act.
Beneficiary or his/her legal representative agrees, understands and expressly
acknowledges the following:
Initial
______Beneficiary or his/her legal representative accepts full responsibility
for payment of the physician’s charge for all services furnished by the
______Beneficiary or his/her legal representative understands that Medicare
limits do not apply to what the physician may charge for items or services
furnished by the physician.
______ Beneficiary or his/her legal representative agrees not to submit a
claim to Medicare or to ask the physician to submit a claim to Medicare.
Initial______ Beneficiary or his/her legal representative understands that Medicare
payment will not be made for any items or services furnished by the
physician that would have otherwise been covered by Medicare if there was
no private contract and a proper Medicare claim had been submitted.
Page 1 of 2 Private Contract
_____ Beneficiary or his/her legal representative enters into this contract
with the knowledge that he/she has the right to obtain Medicare-covered
items and services from physicians and practitioners who have not opted out
of Medicare, and the beneficiary is not compelled to enter into private
contracts that apply to other Medicare-covered services furnished by other
physicians or practitioners who have not opted out.
_____ Beneficiary or his/her legal representative understands that Medi-Gap
plans do not, and that other supplemental plans may elect not to, make
payments for items and services not paid for by Medicare.
______Beneficiary or his/her legal representative acknowledges that the
beneficiary is not currently in an emergency or urgent health care situation.
______Beneficiary or his/her legal representative acknowledges that a copy
of this contract has been made available to him.
Executed on:
____________________
Date
By:
___________________________________
Beneficiary or his/her legal representative
And:
___________________________________
John Ferrell III, M.D.
___________________________________
Victor Ibrahim, M.D.
___________________________________
David Wang, D.O.
Page 2 of 2 Private Contract