Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas Today s Date: How did you hear of our practice?

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1 Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Address: Date of Birth: Age: SSN: Occupation: Employer: Employer s Address: City: State: Zip: Primary Care Physician: Phone Number: In case of emergency, contact: Relationship: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) PRIMARY INSURANCE: Name of Insurance Company: Insured s Name: Relationship to Insured: Insured s SSN: Date of Birth: Member Number: Group Number: SECONDARY INSURANCE: Name of Insurance Company: Insured s Name: Relationship to Insured: Insured s SSN: Date of Birth: Member Number: Group Number: I DO NOT HAVE INSURANCE AND WILL BE PAYING MY CHARGES IN FULL TODAY. Did your injury happen on the job? Yes No If yes, on what date did the injury occur? Did you report the accident to your employer: Yes No Ins/Work Comp Carrier: Claim # Case Manager: Contact Phone Number: Our office will file insurance for all reimbursable services, to both your primary and secondary insurance carriers. Please remember that you are responsible for all deductibles, copay, and non-covered service amounts. See our complete financial policy for details. Must complete all Signatures: I authorize the release of any medical information necessary to the insurance to process my claim: X Date: (Signature of Patient or Responsible party) I authorize payment of medical and surgical benefits to North Texas Orthopaedics & Spine: X Date: (Signature of Patient or Responsible party) 1

2 Name: Today s Date: Date of Birth: Chief Complaint Why are you seeing the doctor today, which side? Right Left Upper Lower: Current problem is a result of a(n): CHECK all that apply: Car Accident Work Accident Sudden Onset Gradual Onset Other PAST MEDICAL HISTORY Please CHECK all medical history that applies High Blood Pressure Thyroid Issues Other: List High Cholesterol Asthma Diabetes: Type I or Type II Migraines Anxiety/ Depression Heart Disease Osteoarthritis Osteoporosis COPD Scoliosis Kidney Disease Liver Disease PAST SURGICAL HISTORY Surgeries/ Hospitalizations Year Complications? Anesthesia Complications? MEDICATIONS Medication Dose Reason for Medication Side effects ALLERGY Medication Allergies/ Reactions (please list all allergies below) 2

3 SOCIAL HISTORY Work in the home Employed (occupation ) Student Daycare Retired Single Married Divorced Separated Widowed Children? No Yes How many: Do you live alone? No Yes History of substance abuse? No Yes What? Smoke Currently? No Yes packs per day for years. Never Quit Smoking This year Less than 1 year Less than 5 years Less than 10 years Smoked packs per day for years. Drink alcohol? Daily 1-2 per week 1-2 per month 1-2 per year Never How often to you exercise? Daily Weekly Rarely Never What type? REVIEW OF SYSTEMS Are you currently having problems with: CIRCLE Describe all Yes responses: Eyes No Yes Ears, Nose, Throat No Yes Lungs, Breathing No Yes Digestion No Yes Bowel movements No Yes Bladder problem No Yes Diabetes No Yes High Blood Pressure No Yes Heart No Yes Bleeding Problems No Yes Balance Problems No Yes Numbness/Tingling No Yes Blackout/Fainting No Yes Psychological Problems No Yes HIV/AIDS No Yes Cancer (any) No Yes Arthritis (any) No Yes Polio No Yes TB No Yes Hepatitis No Yes Signature: (Patient Signature or Responsible Party) Date: 3

4 PHARMACY DESIGNATION FORM Please be aware we will only send your prescription to one local pharmacy and, if you have one, one mail order pharmacy. If you need a refill contact your pharmacy and they will send us the request to be refilled. Allow business hours for the refill to be done. There are certain prescriptions we cannot refill early, however if you are running low please contact the pharmacy within the hour period before you run out so we may refill it in time. Please provide the street address, street name and/or cross street and city if known. Sincerely, NTOS Team Patient Name: Date of Birth Name of Pharmacy: Phone Number: Street Address (or cross streets and city): Signature: Print Name: Date: (Signature of the Patient or Responsible party) If you change your preferred pharmacy, you must notify the clinic and complete a new Pharmacy Designation Form for your file. Forms can be requested at check in. 4

5 FINANCIAL RESPONSIBILITY AGREEMENT Patient Name: Date of Birth: Date: I understand and agree that I will be financially responsible for any and all charges for services not paid by my insurance for my visits. This includes any medical service or visit, preventative exam or physical, lab testing, X-ray, EKG, and any other screening service or diagnostic testing ordered by my physician or the physician s staff. I understand and agree it is my responsibility and not the responsibility of the Physician or clinic to know if my insurance will pay for my medical services or visit, preventative exams, lab testing, X-ray, EKG, or any screening services or diagnostic tests ordered by my physician or the physician s staff. I understand and agree it is my responsibility to know if my insurance has any deductibles, co-pays, co-insurance, out-of-network amount, usual and customary limits, or any other type of benefit limitations for the services I receive and I agree to make full payments. I understand and agree it is my responsibility to know of the physician or provider I am seeing is a contracted innetwork provider recognized by my insurance company or plan. If the physician or provider I am seeing is not recognized by my insurance company or plan, it may result in claims being denied or higher out of pocket expense to me. I understand this and agree to be financially responsible and make full payments. I understand and agree it is my responsibility to know if my PCP choice has been processed by my insurance company or plan. If I have requested a PCP change that is not processed by my insurance company, it may result in claims being denied. I understand this and agree to be financially responsible and make full payments. Signature: (Patient Signature or Responsible Party) Date: Print Name: (Patient or Responsible Party) 5

6 TEXAS HEALTH MEDSYNERGIES PATIENT REGISTRATION FORM DISCLOSURES & CONSENTS Patient Name: Date of Birth: Last Name First Name ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize direct payment of my insurance benefits to Texas Health MedSynergies or the physician individually for services rendered to my dependents, or me, by the physician or those under his/her supervision. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any copay or balance due that Texas Health MedSynergies is unable to collect from my insurance carrier for whatever reason. MEDICARE/MEDICAID/CHAMPUS INSURANCE BENEFITS: I certify that the information given by me in applying for payment under these programs is correct. I authorize the release of any of my, or my dependent s records that these programs may request. I hereby direct that payment of my, or my dependent s authorized benefits be made directly to Texas Health MedSynergies or the physician on my behalf. AUTHORIZED TO RELEASE NON-PUBLIC PERSONAL INFORMATION: I certify that I have read and been offered a copy of the Texas Health MedSynergies. HIPAA Notice of Privacy Practices. I hereby authorize Texas Health MedSynergies. or the physician individually to release any of my, or my dependent s medical or incidental nonpublic personal information that may be necessary for medical evaluation, treatment, consultation, or the processing of insurance benefits. AUTHORIZATION TO MAIL, CALL OR I certify that I understand the privacy risks of the mail, phone calls, and . I hereby authorize a Texas Health MedSynergies representative or my physician to mail, call, or me with communications regarding my healthcare, including but not limited to such things as appointment reminders, referral arrangements, and diagnostic test results. I understand that I have the right to rescind this authorization at any time by notifying Texas Health MedSynergies to that effect in writing. LAB/X-RAY/DIAGNOSTIC SERVICES: I understand that I may receive a separate bill if my medical care includes lab, x-ray, or other diagnostic services. I further understand that I am financially responsible for any co-pay or balances due for these services if they are not reimbursed by my insurance for whatever reason. CONSENT TO TREATMENT: I hereby consent to evaluation, testing, and treatment as directed by my Texas Health MedSynergies physician or those under his/her supervision. PATIENT SIGNATURE: DATE: GUARANTOR SIGNATURE: (if different from patient) DATE: GUARANTOR NAME (Please Print): Confidential Proprietary Information New Patient Registration Packet March

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