(Please arrive 30 minutes prior to your appointment)

Transcription

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 Time (Please arrive 30 minutes prior to your appointment) 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 our are on an HMO or any insurance the requires a referral from a Primary Care Physician, you will need to bring a copy of the referral with you to 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 not 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 Orthopedic Trauma Surgery General Surgery

2 PATIENT ENTRANCE FORM Medical Record # (office use only) Patient s Name (Last) (First) (Middle) Address of Birth / / q Male q Female SSN Work Phone Cell Phone Home Phone Marital Status q Single q Married q Other Spouse s Name Souse s of Birth / / Work Phone Cell Phone Parent/Guardian Names to patient Work Phone Cell Phone Home Phone Emergency Contact Name to patient Phone # Primary Care Physician (Please include first and last name of primary physician and city where they are located.) Full Name, City Phone # Who referred you? q Physician (If physician, include full name and city) q Friend q Coach q Trainer q Other Name Phone # Patient s Occupation Work Phone Patient s Employer (Name of Company) Employer s Address Student If yes, q Full time q Part time School Name Address Sports Played Coach Name Trainer Name Cause of Injury q Work related q Auto accident q Sport q Other of Injury Is there an attorney involved? Attorney s Name Contact Number The information on this form is correct, and I understand that any updates should be made within 10 days of the form date. Signature of Parent/Guardian if minor

3 PATIENT S INSURANCE COVERAGE Today s Name of Patient Please complete the following insurance information that applies to your case and present a photo ID and insurance card(s) to the receptionist. Cause of Injury q Work Related q Auto accident q Sport q Other of Injury Primary Insurance Name Billing Address Insured Person s Name (if different from patient) Insured Person s SSN Insured Person s of Birth / / Insured Person s employer Phone # Employer s Address Policy/ID Number Group Name/Number Secondary Insurance Name Billing Address Insured Person s Name (if different from patient) Insured Person s SSN Insured Person s of Birth / / Insured Person s Employer Phone # Employer s Address Policy/ID Number Group Name/Number Worker s Compensation Insurance (if work related injury) Name of Carrier Carrier Phone # Employer (at time of injury) Phone # Name of your Work Comp Adjuster (if known) Phone # Claim Number Auto/Third Party Insurance/Attorney Name of Insurance Company to be Billed Phone # Adjuster at Insurance Company Phone # Attorney Name Phone # Guardian to a Minor or Other Adult If the patient is a minor or an adult that has a guardian please complete the following for our files: Address Phone # Your Cell Phone Home Phone I understand that I am ultimately responsible for updating the above information and or any other information on this record. Signature of the Patient/Guardian if minor

4 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT 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 healthcare providers who may be involved in that treatment directly or indirectly. Obtain payment from third party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read and understand your 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 above to obtain a current copy of the Notice of Privacy Practices. Patient s Name (Last) (First) (Middle) Do we have permission to... Leave a message on your home answering machine regarding your appointment(s)? Leave a message on your home answering machine asking you to call our office? Contact you at your place of employment? Discuss and or coordinate your treatment plan with other care providers including, but not limited to, Physical Therapists, Trainers, etc. Give the names of the people with whom we can discuss your medical condition, including appointment information May we provide your athletic trainer and their associates with your health information? If yes, Name of Trainer Phone # Signature of the Patient/Guardian if minor OFFICE USE ONLY I attempted to obtain the patient s signature in acknowledgement on the Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below. Initials Reason

5 FINANCIAL AGREEMENT Patient s Name (Last) (First) (Middle) Today s Medical Record # (office use only) I/We (Patient/Parent/Guardian/Guarantor) hereby agree as follows: 1. 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. 2. When the Patient s Insurance coverage is Insufficient: If any insurance coverage which the patient may have, such as Blue Cross, Medicare, Medicaid, Worker s Compensation or any other coverage, rejects the patient s claim, or allow 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. 3. This Agreement: I/We (Patient/Parent/Guardian/Guarantor) have read and understood this Agreement, and have received a copy as well. Patient s Name Patient s SSN Patient s of Birth Signature of Patient Phone # Name of Witness Phone # Signature of Witness Name of Person Guarantying Payment Guarantor s SSN Guarantor s of Birth Signature of Person Guarantying Payment Phone # Guarantor s Home Address (Street Address, Apt. #, State, Zip, P.O Box NOT Accepted) Guarantor s Employer s Name Guarantor s Employer s Address (Street Address, Apt. #, State, Zip, P.O Box NOT Accepted)

6 GENERAL MEDICAL INFORMATION Name Nickname Age Height Weight I am q Right Handed q Left Handed List any allergies List any medications you are taking now Do you have or have you had any of the following conditions: q Diabetes q Ulcer q Arthritis q Thyroid Disease q Intestinal Disease q Cancer q Heart Disease q Hepatitis q Severe Headaches q Hypertension q Liver Disease q Stroke q Asthma q HIV/AIDS q Seizure Disorder q Respiratory Disease q Muscle Disease q Drug Dependency q Kidney Disease q Anemia q Alcohol Dependency List any other medical conditions you have List any previous fractures or joint dislocations List any previous surgeries (month/year performed) Have you ever been given a blood transfusion? q YES q NO When How much do you smoke? q None q packs a day How much do you drink? q None q Where is your pain or problem? (Check all involved): q Neck q Hand q Right q Left q Knee q Right q Left q Shoulder q Right q Left q Fingers q Leg q Right q Left q Arm q Right q Left q Back q Ankle q Right q Left q Elbow q Right q Left q Pelvis q Foot q Right q Left q Forearm q Right q Left q Hip q Right q Left q Toes q Wrist q Right q Left q Thigh q Right q Left q Other When did these symptoms first begin? (, if known) Describe how problem or condition first began

7 PATIENT DEMOGRAPHICS/INSURANCE 800 Fifth Avenue, Suite 500, Fort Worth, Texas Phone: (817) Fax: (817) CONSENT FORM PATIENT NAME: 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 therapy, laboratory tests, x-rays, and MRIs. I acknowledge that no guarantees have been made to me as to results of my treatments, 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, Suite 500, Fort Worth, TX 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 accruing 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 pursuant to this assignment. A photocopy of this assignment shall be as 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 such 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 (Advance 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 governmental 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 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 any 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 am/are the 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 Signed