Welcome to Our Practice:

Transcription

1 Welcome to Our Practice: As a patient, your care and needs are important to us. We would like to ensure that your office visit with us is pleasant and productive. Please complete the attached new patient information forms. If you need assistance with some of the questions, the office staff will be happy to assist you. We would like to apologize in advance for any delay you may experience in seeing the physician for your appointment. The Dallas Orthopaedic Trauma Institute (DOTI) physicians also cover the Trauma Center for Emergency cases that come in during the day. If you are unable to wait we will gladly reschedule you for the next available appointment. Please note we will keep you informed to the best of our ability as to how long your wait may be if such an occurrence is necessary. Please feel free to call the office on the day of your appointment and confirm if your doctor has been called into surgery. For all orthopaedic appointments, the arrival time for your physician appointment is 30 minutes. If you are requested to get X-Rays prior to your appointment, please make sure you check-in at Outpatient Registration, Pavilion 2, Second Floor, 1 hour prior to your physician appointment time. This will allow time to have your X-Ray films or studies done which your physician may have requested. Patients Under the Age of 18 A parent or legal guardian must accompany new patients under the age of 18 to their initial visit. The parent or legal guardian may designate another adult to accompany an existing patient during follow-up visits, if it is specified on a Minor's Consent for Treatment form. This form can be obtained during check-in. What to Bring to your Appointment Insurance Card (Primary & Secondary) A Valid Picture ID Your Referral (if required by your PCP) Your Paper Work Your Co-pay or Required Payments All co-pay and fees are due at time of check-in; if you need to make payment arrangements please ask to speak with the Practice Manager. r I acknowledge that I have received a copy of all new patient paperwork. Signature of Patient/Guardian: Date: Signature of Office Representative: Date:

2 Pavilion 2, Suite 431 REGISTRATION Patient s Last Name: First Name: Middle Initial: DOB: Age: Gender: r Female r Male Address: Home Phone: Cell Phone: City: State: Zip: Social Security Number: Preferred confidential contact: r Phone r Cell r Marital Status: r S r M r D r W Preferred language: Race: r White r Black/African American r Asian r American Indian/Alaska Native r Native Hawaiian/ Pacific Islander r Prefer not to answer Ethnicity: r Hispanic or Latino r Not Hispanic or Latino r Prefer not to answer Employer: Employer Phone Number: Employer Address: Patient's Occupation: Employer City, State, Zip: Pharmacy name: Phone number: PRIMARY AND REFERRING PHYSICIANS FINANCIAL RESPONSIBILITY If person responsible for payment is different from patient, then complete the following section. If patient is a child please indicate whether the parents are r Married r Separated r Divorced Name: Address: City, State, Zip: Employer: EMERGENCY CONTACT INFORMATION Social Security Number: Date of Birth: Home Phone: Cell Phone: Employer Phone: Employer Address: Worker s Compensation r Yes r No If yes, Adjuster s Name: Phone: Primary Insurance: Insurance name: Policy ID#: Group / Account #: Policy Holder Name: DOB: SS# Relationship to patient: Secondary Insurance: Insurance name: Policy ID#: Group / Account #: Policy Holder Name: DOB: SS# Relationship to patient: IN CASE OF EMERGENCY NOTIFY: Name: Phone: Address: Crime Victim r Yes r No Primary Care Physician: Address: Phone: Referring Physician: Address: Phone: Authorization to release information and assignment of benefits: I hereby authorize and assign payment of medical benefits to the provider of services rendered or to be rendered in the future, without obtaining my signature on each claim submitted, and my signature will bind me as though I personally signed each claim. I also authorize the release of any medical information necessary. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES. If my account should be referred to a collection agency, I will be responsible for any collection and/or legal fees. I have read and understand the office policy and procedures. Patient / Responsible Party Date

3 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. This notice is being provided to you in accordance with the requirements of the Standards for Privacy of Individually Identifiable Health Information of the Health Insurance Portability and Accountability Act (HIPAA) and by the amendments to the HIPAA Privacy Rules made by the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act). I acknowledge that I have been provided with Dallas Orthopaedic Trauma Institute s Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the Notice of Privacy Practices prior to signing this consent. I understand that Dallas Orthopaedic Trauma Institute reserves the right to change its Notice of Privacy Practices and prior to implementation will mail a copy of any revised notice to the address I have provided. By signing this form, I consent to Dallas Orthopaedic Trauma Institute s use and disclosure of my health information for treatment, payment, and health care operations. PATIENT INFORMED CONSENT FOR TELEMEDICINE SERVICES Dallas Orthopaedic Trauma Institute has implemented an electronic health record in part to meet the U.S. Department Health and Human Services initiative to improve health information technology, toward the goal of improving quality of health care. Our electronic health record integrates your clinical record with appointments, registration, and billing and makes this information available to the clinicians who are involved in your health care. In connection with its electronic communication systems, DOTI has also implemented and has in place privacy and security policies and procedures to minimize risk of inadvertent or unauthorized disclosure, corruption and/or loss or distortion of data, but as with all record keeping systems, whether paper or digital, some risks remain of loss, inadvertent disclosure or errors in the recorded data. I have read and understand the information provided regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine including electronic transfer of medical data to other medical practitioners participating in my medical care. I hereby authorize Dallas Orthopaedic Trauma Institute to use telemedicine in the course of my diagnosis and treatment and consent to the electronic communication of my personal health care information to other entities for treatment, payment or health care operations. INFORMED CONSENT FOR PRESCRIPTIONS Dallas Orthopaedic Trauma Institute continues its position as the network exchange for the flow of vital patient information to physicians and other health care providers. It is essential to improve patient safety and the continuity of care with electronic connectivity between payers, physicians and pharmacists. Dallas Orthopaedic Trauma Institute s electronic health record (EHR) provides secure access for patients with commercial prescription coverage in the United States. Prescription eligibility, benefit, formulary and medication history information is provided for consenting patients to authorized physicians at the point of care. Electronic prescriptions are delivered in real-time to pharmacists in the retail and mail order settings. I consent to electronic prescriptions and acknowledge that Dallas Orthopaedic Trauma Institute will use electronic connectivity between payers, physicians and pharmacists. Signature of Patient/Legal Representative Date Witness Date

4 Pavilion 2, Suite 431 DEMOGRAPHICS Patient s Name: DOB: Age: Do you have an Advance Directive? r Yes r No Gender: Primary Care Physician: Phone: Referring Physician: Phone: Allergies: Please list any allergies to medication, latex, food or environment (please list reaction): r None CHIEF COMPLAINT CURRENT PROBLEM MEDICAL HISTORY PRIOR MEDICAL HISTORY Please indicate by checking the box if you have any of the following conditions: PAGE 1 OF 3 Employment status: r Disabled r Full Time r Light Duty (how long? ) r Retired r Student r Unemployed r Unemployed due to this problem When was the last day you worked your regular job? Are you currently or have you ever been on disability due to a health condition? r Yes r No If yes, what condition are you on disability for? When did you last work? What is the reason for your visit? Have you had a problem like this before? r Yes r No Were you seen in the ER for this problem? r Yes r No Which ER? Date: Is any litigation pending regarding this injury? r Yes r No Have you received any other treatment for this condition? r Yes r No Where/Who? When? Treatment: Where/Who? When? Treatment: If an injury, did it occur: r At work r In an auto accident Abnormal Chest X-ray Depression Hemorrhoids Pleurisy Abnormal EKG Diabetes Hepatitis Pneumonia Abnormal Mammogram Disease Hernia If Yes, Date: Anemia Diverticulitis Hiatal Hernia Poor Scarring Anxiety Disorder DVT High Blood Pressure Pulmonary Embolism Arthritis Emphysema High Cholesterol Rheumatic Fever Asthma Epilepsy HIV or AIDS Rheumatoid Arthritis Atrial Fibrillation Gallbladder Hypertension Seizures/Epilepsy Auto-Immune Disorders Gastroenteritis Kidney Disease Sexually Transmitted Disease Bleeding Disorder GERD / Reflux Kidney Failure Stroke Bleeding Tendencies Glaucoma Kidney Stone / Problems Taking Blood Thinners Blood Clots Gout Leg or Foot Ulcers Thyroid Disorder Cancer Hearing problems Liver Disease Thyroid Problems Cardiovascular Disease Heart Attack (MI) Migraines Tuberculosis Cataracts Heart Disease Mitral Valve Prolapse Ulcers Chronic Pain Heart Murmur Myocardial Infarction Urinary Tract Infection Cirrhosis Heart Problems Osteoporosis Other: COPD Heart Surgery Pacemaker Coronary Artery Disease Heart Valve Disease Peptic Ulcer Crohn's Disease Hemophilia Peripheral Vascular Disease

5 PREVIOUS SURGICAL HISTORY Please list any operations or hospitalizations you have had. Please list the year of surgery as well as the surgeon and the city where hospitalizations took place. Type Year Surgeon City Have you or a family member had a reaction to anesthesia? r Yes SOCIAL PAGE 2 OF 3 r No If yes describe: Do you smoke tobacco? r Never r Previously, but quit r Yes packs a day Do you drink alcohol? r No r Yes number per week Occupation: Employment status: r Disabled r Full Time r Light Duty (how long? ) r Retired r Student r Unemployed r Unemployed due to this problem When was the last day you worked your regular job? Are you currently or have you ever been on disability due to a health condition? r Yes r No If yes, what condition are you on disability for? When did you last work? FAMILY HISTORY Please check any of the problems listed below which apply to your immediate family members. Mother: r Living Age: Diabetic: r Whom? Degerative Arthritis: r Whom? r Deceased Age: Father: r Living Age: r Deceased Age: High Blood Pressure: r Whom? Heart Disease: r Whom? Rheumatoid Arthritis: r Whom? Other: r Whom? Other: r Whom? Other: r Whom? CURRENT MEDICATIONS Are you currently being prescribed narcotics (like Vicoden or Percocet) or any other controlled substance (like valium or Ativan) by another medical provider? r Yes r No List any medication you are taking at this time. Include such items as aspirin, vitamins, laxatives, calcium supplements, etc. Name of Medication: Doseage: Frequency: Start Date: PHARMACY INFORMATION Name of Pharmacy: Address and / or Crossroads: Pharmacy Phone Number

6 PAGE 3 OF 3 REVIEW OF SYSTEMS Indicate by checking yes or no to any you have had in RECENT months. Circle the symptom(s) you have had. Symptom Yes No How long / where? Skin Rash, sore or excessive bruising? r r Numbness or tingling? r r Fever, night sweats, or chills? r r Frequent nosebleeds? r r Cough, shortness of breath, wheezing or asthma? r r Chest pain or pressure? r r Exposed to anyone with tuberculosis? r r Blacked out, lost consciousness or had a seizure? r r Abnormal swelling of legs or feet? r r Pain in calves of your legs when you walk? r r Change in bowel or bladder habits? r r Pain, stiffness, or swelling in your joints or back? r r Do you feel you are at risk for HIV or AIDS? r r Muscle weakness? r r Dizziness or falling? r r Travel outside of the US? r r I hereby certify that the above information is true and correct to the best of my knowledge. Patient / Representative Printed Name Signature Date Review by Physician Printed Name Signature Date

7 CONSENT FOR MEDICAL CARE AND TREATMENT I understand that I may have a medical condition that could possibly require diagnosis and treatment. I do hereby voluntarily consent to such treatment, services, and procedures that may be recommended under the general and specific instructions of the physicians of Dallas Orthopaedic Trauma Institute, his/her assistants, or his/her designee. I acknowledge that the practice of medicine is not an exact science and that the physicians of Dallas Orthopaedic Trauma Institute have made no guarantees to me as to the result of treatments or examination. Dallas Orthopaedic Trauma Institute recognizes the importance and significance of maintaining Confidentiality of information regarding a patient s medical condition. We also want to provide our patients timely communication as to laboratory/diagnostic test results, etc. We understand that because of the patient s schedules and our office schedules, this may sometimes be difficult. Dallas Orthopaedic Trauma Institute would not, under any circumstances, leave messages regarding sensitive medical information. Acknowledging that it may be difficult for the physician/physician s staff to personally communicate with the patient regarding laboratory/diagnostic test results, etc., it is the policy of Dallas Orthopaedic Trauma Institute to leave this information on the patient s telephone answering machine. If the physician/physician s staff cannot reach the patient at the home or business telephone, it is the policy of Dallas Orthopaedic Trauma Institute that a message will be left with the person that answers the telephone to advise the patient to return the phone call. It is the policy of Dallas Orthopaedic Trauma Institute not to release confidential medical information to patient s family members. We cannot discuss your medical condition, or release diagnostic test results to anyone without your consent. r I agree r I do not agree Information regarding my medical condition, including laboratory and diagnostic test results, can be given to (name of designated person or persons): Relationship Relationship 3. Relationship Relationship Relationship Relationship Signature of Patient Date Signature of Witness Date

8 Practice Financial Policy Medical Insurance Providing quality medical care to our patients is our primary concern. In order to accommodate the needs of our patients, we have enrolled and contracted with many health plans. With your cooperation and assistance, you should be able to receive all of the benefits offered to you by your health plan allowing our physicians the opportunity to concentrate on caring for your medical needs. In order to facilitate your care, we ask that you read and follow these guidelines. Please bring your insurance card to all office appointments. If you have an HMO or other managed care policy, you must obtain a referral from your PCP as instructed by your insurance company. Due to HMO regulations and restrictions, we may have to cancel or reschedule your appointment until a referral is obtained. Depending on your particular plan, please verify the number of visits permitted. You will be responsible for any visit not authorized. We will collect all applicable co-pays, co-insurance, and deductibles at the time of service. In all cases, our office collects an estimate of your financial responsibility. We submit all claims to your insurance carrier and the insurance company then designated the definitive patient responsibility. We will credit any overpayment in a timely manner. If you have a responsibility greater than what was originally collected, our office will send you a statement for the additional portion. You may contact our Financial Counselor to make arrangements for payment. Third Party Liability Carrier Our practice does not take part in third party liability cases such as an auto accident. We recommend before using your private insurance, to contact the third party carrier to verify the company is willing to reimburse any out of pocket expenses that will occur. We will collect all applicable co-pays, co-insurance, and deductibles according to your insurance plan at the time of service. You may request an itemized receipt to provide to your third party carrier to show proof of payment. Dallas Orthopaedic Trauma Institute does not file claims through third party liability insurance companies such as auto insurance. Should your medical insurance company deny or request a refund for payments made, all charges will be your responsibility. Crime Victim Please notify our office if you are a victim of a violent crime and/or have applied for the Crime Victims' Compensation (CVC) Program. If you have your Crime Victim account number, please provide this information upon check-in. Worker s Compensation Worker s Compensation claims are handled directly with the carrier and case managers in your recovery. Your recovery and returning to work takes a partnership with you, your case manager, and our physicians. Should your claim be denied or deemed not compensable by the worker compensation carrier, all charges will be your responsibility. If you have sustained an injury on the job and have a worker s comp claim, Texas Worker s Comp Commission bylaws prohibit us to accept your private insurance nor can we accept any payments for your office visit. Self Pay Payment is expected at the time services are rendered. However, treatment decisions are based solely on the patient s medical needs. Dallas Orthopaedic Trauma Institute will not deny critical care to anyone due to their inability to pay or lack of insurance. Patients who have financial constraints should speak to a financial counselor for assistance.

9 Office Hours Our office hours are Monday Friday, 8:30 am 4:30 pm. We are closed 12:00 noon 1:00 pm for lunch daily. Emergencies Dallas Orthopaedic Trauma Institute provides patient care 24 hours a day. It would be greatly appreciated if our patients would complete routine patient care activities during regular business hours, as our on-call physicians are frequently called upon for emergency surgery or hospital related business. If you need the physician after-hours, our office number will connect you to our telephone answering service. These individuals have special instructions and know where to reach the physician on call. Since our physicians share call responsibilities, please understand that you may not be able to communicate directly with your personal physician. Please note the physician on call will not authorize medication refills or prescribe new medication. Due to emergencies, you may occasionally be seen by one of your doctor s partners. Be assured your care will be reviewed by your regular physician and no break in continuity of care will occur. If you feel you have a life-threatening emergency, please dial 911 or go to your nearest emergency facility. Prescriptions Medications can only be prescribed by a physician, If you require a prescription or prescription refill, please contact your pharmacy first. The pharmacy will contact our office. Prescriptions are refilled Monday thru Friday between the hours of 8:30 am - 3:00 pm. All refill requests received after 3:00 pm may be called in the following business day. Medications are not refilled over weekends, evenings or holidays; please anticipate weekend, evening and holiday medications needs by initiating your request by noon Monday through Friday. Allow 24 hours for all refills to be approved. Disability/FMLA Forms We will complete forms for patients that have undergone treatment by our physicians only. There will be a $25.00 charge for each set of forms. This charge is payable in advance when the forms are submitted to us for completion. Please allow 7-10 working days to complete paperwork. Medical Forms CANNOT be completed on the day forms are presented to the office. Medical Records Copies of records or request for transfer of records to other physicians or facilities must be in writing. Please allow 3-5 working days to process request. Please contact our health information personnel for all requests

10 Patient Rights and Responsibilities We consider you a partner in your care. When you are well informed, participate in treatment decisions, and communicate openly with your doctor and other health professionals, you help make your care as effective as possible. Dallas Orthopaedic Trauma Institute encourages respect for the personal preferences and value of each individual. It is our goal to assure that your rights as a patient are observed. You and your family have the right to access an interpreter if you are deaf or do not speak or understand English. All patients have a right to refuse a recommended treatment, to the extent permitted by law, and to be informed of the medical consequences of this action. All patients are responsible for their own actions if they refuse treatment or do not follow the physician s recommendations. All patients have the right to every consideration of privacy. Patients are responsible for being considerate of the privacy of other patients. Telephones, television, radios, and lights should be used in a manner agreeable to others. All patients have the right to expect that all communications and records pertaining to their care will be treated as confidential, except in cases such as suspected abuse and public health hazards, when reporting is permitted or required by law. All patients have the right to receive an explanation of their bill, regardless of the source of payment. Patients have the responsibility to provide information necessary for claim processing and to be prompt in payment of their bills. All patients have the right to know the rules and regulations that apply to patient care and conduct and are responsible for following those rules and regulations. All patients have a right to receive an explanation of their treatment program and to ask for further clarifications if the course of treatment is not understood. Patients have the responsibility to cooperate in their treatment program.

11 Notice of Privacy Rights Each time you visit Dallas Orthopaedic Trauma Institute, a record of your visit is made. Typically, this record contains your symptoms, examinations and test results, diagnosis, and a plan for future care and treatment. This information, often referred to as your health or medical record, serves as a: Basis for planning your care and treatment Means of communication among the many health professionals who contribute to your care Legal document describing the care you received Means by which you or a third party payer can verify that services billed were actually provided Tool in educating health professionals Source of data for medical research Source of information for public health officials charged with improving the health of this state and the nation Source of data for our planning and marketing Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others. Dallas Orthopaedic Trauma Institute is required to: Maintain the privacy of your health information Provide you with this notice as to our legal duties and privacy practices with respect to your information we collect and maintain about you Abide by the terms of this notice Notify you if we are unable to agree to a requested restriction Accommodate reasonable requests you may have to communicate health information by alternative locations. We reserve the right to change our practice and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you have provided us. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue using or disclosing your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.