New Patient Form - Wyoming Surgical Associates

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New Patient Information

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WYOMING SURGICAL ASSOCIATES, P.C.

James A. Anderson, MD
Todd H. Beckstead, MD
Brock A. Anderson, MD
Matthew P. Doering, MD
Kevin D. Helling, MD
Clayton E. Turner, MD
Aimee E. Gough, MD

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MEDICATIONS CURRENTLY TAKING
Date:
Date Format: MM slash DD slash YYYY
Patient's First Name:
Patient's Last Name:
Date of Birth:
Date Format: MM slash DD slash YYYY
Are you currently taking any blood thinners?
- Yes
- No
Are you diabetic?
- Yes
- No
Please list all allergies:
What Pharmacy do you want us to send prescriptions to?
Name of Medication, Dose (mg), How often do you take?

(One medication per line)

Date:
Date Format: MM slash DD slash YYYY
Referring Dr or Primary Care Dr if not referred:
Patient Legal Name:*
First Last
Age:
Birth date:
Mailing Address:
Street Address Address Line 2 City State ZIP Code
Home Phone:*
Cell Phone:
Social Security #:
Email Address:*
Marital Status:
- Single
- Married
- Divorced
- Widowed
- Male
- Female
Employer:
If retired, please put retired/date of retirement. If student, please put name of school/part or full time
Employer Phone Number:
SPOUSE INFORMATION
Spouse Name:
First Last
Age:
Birth Date:
Date Format: MM slash DD slash YYYY
Social Security Number:
Employer:
(If retired, please put retired/date of retirement)
Employer Phone Number:
Cell Phone:
RESPONSIBLE PARTY (IF OTHER THAN PATIENT PLEASE FILL IN BELOW)
Name & Relationship:
Social Security Number:
Mailing Address:
Street Address Address Line 2 City State ZIP Code
Birth Date:
Date Format: MM slash DD slash YYYY
Employer:
Phone Number:
EMERGENCY INFORMATION
Name of friend or relative:
Relationship:
Phone Number:
Address:
Street Address Address Line 2 City State ZIP Code
Please note that we now require a copy of your Medicare, Medicaid and or Insurance Card to verify the mailing address, phone number and the spelling of your name as shown on each individual card. We can not file insurance claims for you without the birthdate and social security number of the policy holder.

We are also requiring a copy of your driver’s license or other picture id that includes your signature. This is to be able to verify your identity in the event of requests for release of Private Health Care information.

We appreciate your help and understanding of these requests.
PRIMARY INSURANCE INFORMATION
Primary Insurance Carrier:
Insurance Policy Number:
Insurance Group Number:
Insurance Company Address:
Street Address Address Line 2 City State ZIP Code
Insurance Company Phone Number (member services):
Name of Insurance Policy Holder:
Relationship of Policy Holder to you:
Policy Holder’s Birth date:
Date Format: MM slash DD slash YYYY
Policy Holder’s Social Security Number:
SUPPLEMENTAL INSURANCE INFORMATION
Supplemental Insurance Carrier:
Supplemental Insurance Policy Number:
Supplemental Insurance Group Number:
Supplemental Insurance Company Address:
Street Address Address Line 2 City State ZIP Code
Name of Supplemental Insurance Policy Holder:
Relationship of Supplemental Policy Holder to you:
Supplemental Policy Holder’s Birth date:
Date Format: MM slash DD slash YYYY
Supplemental Policy Holder’s Social Security Number:
AUTHORIZATION AND FINANCIAL UNDERSTANDING
- By accepting the medical services provided to me by James A. Anderson, MD, Brock A Anderson, MD Todd H. Beckstead, MD, Mattew P. Doering, MD, Kevin D. Helling, MD, Aimee Gough MD, and/or Clayton E Turner, MD or any other employee of the corporation, I agree to be financially responsible for the charges billed by Wyoming Surgical Associates, P.C. for those services.
- f there is medical insurance which will cover all or a portion of the charges I incur by James A. Anderson, MD, Brock A Anderson, MD, Todd H. Beckstead, MD, Matthew P. Doering, MD, Kevin D. Helling, MD, Aimee Gough, MD and/or Clayton E Turner, MD or any other employee of the corporation for my treatment, I hereby assign those insurance benefits to Wyoming Surgical Associates, P.C., and authorize the insurance benefits to be paid directly to Wyoming Surgical Associates, PC. This assignment will remain in effect until revoked by me in writing.
- I understand and agree that if my insurance benefits do not cover all of the charges for my treatment, including what my insurance company classifies as over reasonable and customary charges, that I am responsible to pay any outstanding balances. I further agree that in the event of non-payment to Wyoming Surgical Associates, PC of any amounts due under this agreement I will pay interest thereon at the rate of 1.75% per month and pay all of Wyoming Surgical Associates, PC reasonable legal fees, attorney fees and court costs that may be incurred. I agree that in the event this agreement is assigned to a collection agency for collection I promise to pay a collection fee of 35% of the unpaid balance due which is in addition to the unpaid balance due under this agreement.
- I understand that it may be necessary for Wyoming Surgical Associates, P.C. to disclose medical information about my treatment to my insurance companies, employer, or third-party payers in order to process a claim on my behalf.
- A photocopy of this assignment and financial agreement is to be considered as valid as the original.
- I understand that it is my responsibility to contact my insurance company for pre-authorization on procedures.
I hereby give my permission for any employee of Wyoming Surgical Associates, PC as well as any physician’s office or facility to which I may be referred to contact me at:
- My work phone
- My work phone and leave a message to call back
- My home phone and leave a message to call back
- My home phone and leave a detailed message on either an answering machine or with whoever answers the phone.
- Any other verbal or written contact I have provided to your office for both call back and detailed messages.
Please uncheck any of the below that you do not want us to do.

Chief Complaint (symptoms):
HISTORY OF PRESENT ILLNESS:
How long have you had this problem?
What makes your problem worse?
What makes your problem better?
REVIEW OF SYSTEMS:
Check any problems that you have experienced recently or for prolonged periods in the past:
General:
- Weight loss
- Weight gain
- Weakness
- Fever
- Chills
- Night sweats
Skin:
- Rash
- Non-healing wounds
Eyes:
- Blurred vision
- Loss of vision
- Glaucoma
Ears
- Deafness
- Ringing
- Discharge
- Pain
Nose
- Bleeding
- Discharge
- Obstruction
Mouth
- Bleeding gums
- Sore areas
- Open wounds
Throat:
- Recent sore throat
- Difficulty Swallowing
- Hoarseness
- Tonsillitis
Neck
- Pain
- Stiffness
Breasts:
- Discharge
- Lumps
- Pain
- Bleeding
Lungs:
- Cough
- Sputum change
- Coughing of blood
- Shortness of breath
Heart:
- Pain in chest
- Swelling of legs
- History of Rheumatic Fever
- Fluttering of heart
- Heart murmur
Vascular:
- Pain or cramps in legs after walking
- Varicose veins
- DVT (Blood Clot)
Gastrointestinal:
- Nausea Vomiting
- Vomiting of blood
- Heartburn
- Black stools
- Dark urine
- Hernia
Urinary tract:
- Pain on urination
- Dribbling
- Loss of urine
- Blood in urine
Musculoskeletal:
- Broken bones
- Arthritis
- Stiff joints
- Muscle weakness
- Slurred speech
Neurological:
- Seizures
- Numbness
- Paralysis
- Headache
Psychiatric problems:
- Depression
- Nervousness
- Altered sleep (more)
- Altered sleep (less)
- Change in appetite
PAST MEDICAL HISTORY:
Heart Disease (including heart attack, angioplasty, coronary bypass surgery)?
- Yes
- No
Any other medical or health problems?
Past surgeries:
Social History:
- Married
- Single
- Divorced
- Widowed
Number of children?
Type of employment?
Habits?
- Smoke
- Chewing Tobacco
- Alcohol
- Drug Use
- Exercise
Family Medical History:
Mother?
- Living
- Deceased
If deceased, cause of death?
Father?
- Living
- Deceased
If deceased, cause of death?
History of any of the following in family?
- Heart Disease
- Diabetes
- Lung Disease
- Breast Cancer
- Colon Cancer
- Other Cancer
Other cancer, if selected:

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419 S. Washington St. #200
Casper, WY 82601

Phone: (307) 577 – 4220
(800) 219 – 6619
Fax: (307) 235 – 0931

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