Orthopedic Specialty Associates, P.A.

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1 Orthopedic Specialty Associates, P.A. TEL FAX Keith C. Watson, M.D. Reconstructive Surgery of the Shoulder and Elbow John E. Conway, M.D. Reconstructive Surgery of the Shoulder, Elbow and Knee Sports Medicine Date Time (Please arrive 30 minutes prior to your appointment and bring completed forms) TO OUR NEW PATIENT: We are glad that you have chosen Orthopedic Specialty Associates, P.A. and appreciate the opportunity to participate in your orthopedic care. Please complete the enclosed forms and bring them with you to your appointment along with your insurance card(s) and your drivers license and other proper identification. If you are on an HMO or any insurance that requires a referral from a Primary Care Physician, you will need to bring a copy of the referral with you or the appointment may need to be rescheduled. We ask that on future visits that you notify the Front Desk of any and all changes in your information such as phone numbers, addresses, change in employer and insurance(s). The following is information on different types of visits. We hope this helps answer some questions you may have about your upcoming visit to Orthopedic Specialty Associates. Please bring any diagnostic tests (MRI, X-rays). Tests that are pertinent to your condition are very important. Our doctors require the actual films from these tests as well as the report and you will need to bring these things with you. Please contact the facility where these were done and make arrangements to have these loaned to you for your appointment. Without these, proper evaluation is no t possible and your appointment may need to be rescheduled. Cory A. Collinge, M.D. Adult Reconstruction Orthopedic Trauma Surgery Damond Blueitt, M.D. Primary Care Sports Medicine Derek Dombroski, M.D. Orthopedic Trauma Surgery General Surgery Curtis A. Bush, M.D. Reconstructive Surgery of the Upper and Lower Extremities Sports Medicine

2 Orthopedic Specialty Associates Patient Entrance Form (Last) (First) (Middle) Address City/State Zip Cell # Home # Work # Other # SSN DL Sex Male Female DOB Ethnicity Language Marital Status Single Married Other Spouse s Cell # Occupation Employer City/State Student No Yes FT / PT School City/State List all sports played Coach Phone # Athletic Trainer Phone # Cause of Injury Work related Auto accident Sport Other Date of Injury Is there an attorney involved? No Yes Attorney s Contact Number Who referred you to this office? Physician Coach Trainer Friend Other PCP PCP # City/State Emergency Contact Phone #(s) Relationship Emergency Contact Phone #(s) Relationship If a minor, please provide parent/guardian information Mother Phone #(s) Father Phone #(s) Guardian Phone #(s) Primary Insurance name Phone # Billing Address City, State, Zip Insured Person s (if different than patient) Relationship Insured Person s SSN DOB Employer Policy/ID Number Group Number Employer Phone # Secondary Insurance name Phone # Billing Address City, State, Zip Insured Person s (if different than patient) Relationship Insured Person s SSN DOB Employer Phone # Policy/ID Number Group Number Phone # Workers Compensation Insurance (if work related injury) of Carrier Phone # Claim # Employer (at time of injury) Phone # Adjuster The information on this form is correct, and I understand that I am responsible for updates. Signature of Patient (Parent/Guardian if minor) Date

3 Texas Health Physicians Group Health Information Exchange Authorization Texas Health Physicians Group (THPG) participates in health information exchanges as described in the Texas Health Resources Health Information Exchange Patient s Frequently Asked Questions document which may be revised at any time. A Health Information Exchange (HIE) is an organization that oversees and governs the exchange of health-related information among organizations according to nationally recognized standards. A Health Information Exchange is an electronic health information system that stores your patient health information from multiple healthcare providers participating in the HIEs. It allows your other health care providers to view your past health information for continued care and other uses included in the provider s Notice of Privacy Practices. Your information will be stored within the HIE system, but it will not be visible to or able to be used by providers unless you opt-in to participate. I understand that my medical records are confidential and cannot be disclosed without my written authorization except when otherwise permitted or required by law. I understand that my medical information may include communicable disease information including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), records related to mental health treatment and alcohol and substance abuse diagnosis or treatment, and I authorize release of that information as part of my medical record. Providers will attempt to exclude clearly identified mental health and substance abuse health information from HIEs; however some information may be included. I authorize the above provider to disclose my medical information described above to the HIEs in which THPG participates. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by other providers and such information may no longer be protected. I understand that treatment or payment cannot be conditioned on my signing this authorization. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon this authorization. I may submit a revocation request to the above provider for processing. This authorization will remain effect indefinitely, unless I revoke in writing. The HIE is not able to manage restrictions on disclosure of your health information. A restriction is a request by the patient to not disclose certain information to certain people or companies. If the restriction is or was agreed to by us or other participating HIE healthcare providers, then you must elect to opt-out of the HIE in order to protect your restriction. This must be done at each HIE participating provider you visit. I authorize release of my medical information to the Health Information Exchange in which THPG participates: Acknowledgement: I, the undersigned, certify that I have read and fully understand the information in this Health Information Exchange Authorization form. I understand that if I need to change my information I have provided on this form, I will notify a staff member promptly. Print Patient s Date of Birth Address Signature / Patient or Authorized Representative Relationship Date Witness Title Date

4 Notice of Privacy Practices Acknowledgment I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow up among multiple health care providers who may be involved in that treatment directly or indirectly; Obtain payment from third party payers; Conduct normal health care operations such as quality assessments and physician certifications; Conduct research. I have received, read and understand the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that OSA has the right to change its Notice of Privacy Practices from time to time and that I may contact their Compliance Officer at any time at the address below to obtain a current copy of the Notice of Privacy Practices. Patient (Last) (First) (MI) Do we have your permission to: 1. Leave a message on your answering machine regarding your appointment(s)? Yes No 2. Leave a message on your answering machine asking you to call our office? Yes No 3. Contact you at your place of employment? Yes No 4. Discuss and or coordinate your treatment plan with other care providers including, Yes No but not limited to Physicians, Therapists, Athletic Trainers, etc. s of People with whom we can discuss your medical condition, including appointment information: May we provide your athletic trainer, school coach, team physician and their associates with your health information? Yes No Print Patient s Date of Birth Address Signature / Patient or Authorized Representative Relationship Date Witness Title Date

5 Orthopedic Specialty Associates Financial Agreement Guaranty of Payment: Medical Care has been or will be provided to the patient whose name appears below. I/We (Patient/Parent/Guardian/Guarantor), both jointly and individually, shall be fully responsible for payment for the patient s physician bill, based upon the charges posted by the physician and or his/her associates. The physician may demand full payment of the patient s bill at any time, but the physician is not required to do this. Even if the physician doesn t demand immediate payment, my/our (Patient/Parent/Guardian/Guarantor) obligation to make such payment remains the same. When the Patient s Insurance Coverage is Insufficient: If any insurance coverage which the patient may have (including Medicare, Medicaid, Workers Compensation or any other coverage) rejects the patient s claim or allows only part of the claim (not a covered benefit/not medically necessary), I/We (Patient/Parent/Guardian/Guarantor) shall be responsible for immediate payment of the balance due, as determined by the physician. Deductible/Co-Insurance: Services provided by Orthopedic Specialty Associates such as x-rays and injections may be applied to your deductible or co-insurance. Injections are considered by standardized billing and coding standards to be a surgical procedure and sometimes applied to your deductible in addition to your office visit co-pay. The cost of medication used in the injection may also be applied to your deductible in addition to your office co-pay. Notice: If your insurance company requires a referral, it is the patient s responsibility (or guarantor) to obtain the referral prior to your appointment. We urge you to check with your insurance plan (the customer service is most often on the back of the card) to clarify your benefits in these instances, and to explain to you what is covered and will be paid for services rendered at Orthopedic Specialty Associates. This Agreement: I/We (Patient/Parent/Guardian/Guarantor) have read and understood this agreement. Patient SSN DOB Address Phone Guarantor SSN DOB Address Phone Employer Address Phone Patient Signature Date Guarantor Signature Date

6 Orthopedic Specialty Associates CONSENT TO TREAT Patient DOB Date Authorization for Medical Treatment: I hereby authorize OSA physicians and their associates, and or therapists in charge of my care to administer any treatment as may be necessary or advisable in the diagnosis and treatment of my care. This authorization includes, but is not limited to routine diagnostic procedures, rehabilitation, tests or procedures. I also authorize copies of the medical records to be released to other physicians and health care facilities as deemed necessary by my physician or therapist. Patient Rights: I, the undersigned, have received a copy of the Patient s Bill of Rights, informing of my rights and responsibilities as a patient. Assignment of Facility Benefits: I/We assign all benefits to OSA, and authorize direct payment to OSA, located at th Avenue, #500, Fort Worth, Texas 76104, all insurance benefits or Medicare/Medicaid benefits to which I/we may be entitled. This assignment specifically includes, but is not limited to, major medical and disability insurance proceeds and benefits. It also includes proceeds and benefits accursing under any settlement, structured or otherwise, or awarded in judgment for personal injuries caused by a third party. I/We agree to pay for any and all charges not paid or pursuant to this assignment. A photocopy of this assignment shall be valid as the original. Statement of Financial Responsibility: I understand that I am financially responsible to OSA, as the patient, parent, guardian, and conservator or insured for all charges covered by the above assignment, which charges may include any medical insurance, deductibles and co-insurance. I understand that to sign as a guarantor means that if the patient does not pay OSA for all charges due, I, as a guarantor will be responsible for payment. Non-covered Medicare/Medicaid Services: Medicare/Medicaid and other Third Party Payers have certain outpatient procedures that are excluded from coverage, including but not limited to those of routine diagnostic workups or routine physical examinations. If the patient s medical chart indicates that the patient s treatment is one for which no Medicare/Medicaid benefits are allowable, I understand that all charges incurred during treatment will be the patient s own financial responsibility. There are other limitations and charges for which the patient may be responsible; the patient will be provided additional information with regard to these charges and limitations on a separate written form (Advanced Beneficiary Notice). Authorization to Release Information to Insurance Company/Third Party Payer: I authorize OSA, and any physician, therapist, practitioner, pharmacist, or other person, any hospital including Veteran s Administration or government hospital, any medical service organization, any insurance company, or any other institution or organization to release any medical information about the patient necessary to determine any benefits which may be payable for this treatment. Authorization for Quality Review: I acknowledge that it may be appropriate for OSA to review the overall care provided to patients prior to and following the patient s treatment. I understand that this review is for the sole purpose of maintaining and improving the overall quality of health care provided to OSA s patients. Therefore, I authorize the physicians and therapists and other health care professionals who cared for me at OSA to provide OSA with the copies of records regarding my care that pertain to the treating diagnosis as needed for quality review purposes. This consent is valid for the care provided to me for up to 12 months before and no longer than three months after my treatment at OSA. Personal Valuables: OSA shall not be liable for the loss of or damage to personal property. Assignment of Benefits: I/We assign to Medical Staff Physicians and therapists, and authorized direct payment to OSA all insurance benefits or Medicare benefits to which we may be entitled. This assignment specifically includes, but is not limited to, major medical and disability insurance proceeds and benefits accruing under any settlement, structured or otherwise, or awarded in judgment for personal injuries caused by a third party. I/We agree to pay OSA for any and all charges not paid pursuant to this assignment. A photocopy of this assignment shall be as valid as the original. The undersigned certifies that I have read the foregoing and is the patient or parent(s) or am/are duly authorized by or on behalf of the patient to execute the above to accept its terms. Patient Signature / Parent OR Guardian (if Minor) / Power of Attorney Date

(Please arrive 30 minutes prior to your appointment)

(Please arrive 30 minutes prior to your appointment) Orthopedic Specialty Associates, P.A. TEL 817.878.5300 FAX 817.878.5307 Keith C. Watson, M.D. Reconstructive Surgery of the Shoulder and Elbow John E. Conway, M.D. Reconstructive Surgery of the Shoulder,

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