Currently living in a Skilled Nursing Facility? If Yes:
Referring Physician (REQUIRED FIELD)
Preferred Pharmacy (REQUIRED FIELD) If you do NOT have a pharmacy, please choose one today.
In Case of Emergency: Emergency Contact
Billing Information : If Guarantor is not patient, please provide additional contact below.
Primary Insurance Carrier:
Secondary Insurance Carrier:
Past Surgical and Medical History
Please List All Past Surgeries And Dates:
Please List ALL Current Medications:
Drug Allergies: Please List all Medications You Are Allergic to:
Orthopaedic and Systems Screen: Please CHECK all items that apply
Family History: Please Write Immediate Family member that has had indications below:
Acknowledgement – Receipt of Notice of Privacy Practices
By my signature below, I acknowledge that I have received Southwest Orthopaedic Group’s Notice of Privacy Practices.
Who may we give information to regarding your condition, treatment, or diagnosis?
Is there anyone who should never have this information:
Please list the contact phone numbers where we are able to contact you:
Please sign and date below:
This document provides you with the financial policies used by Southwest Orthopaedic Group. In order to be seen by one of our providers you must initial and sign this form. If you have any questions please ask a staff member.
Consent to pay for services rendered: Copayment, co-insurance and deductibles are required for all services at the time the services are rendered. We accept Medicare, Worker’s Comp and many commercial insurance plans. We will send your claim to your insurance company and any balance that is unpaid by your insurance company will be forwarded to you for payment. It is your responsibility to verify with your insurance plan if we are a contracted provider and to understand your coverage benefits under your policy. For your convenience, we accept Visa, MasterCard, American Express and Discover.
Please read and initial the following regarding our financial policies:
NO SHOW Policy
Your doctor will prescribe an individual treatment plan to care for your condition. This treatment plan will require commitments from both you and your doctor.
Once this treatment plan is agreed to, your doctor will need to monitor your progress and may require you to attend visits in our offices. In order to ensure the availability of appointments for those in need, we have established a “NO SHOW” policy for our practice.
A “NO SHOW” appointment occurs when you do not show up for a scheduled appointment, arrive late, or when you cancel your appointment with less than one business day’s notice (24 hours), as noted above. If you fail to attend 3 (three) appointments in a six month period of time, you will be discharged from our practice. If you are discharged, you will not be allowed to make future appointments with any physician in our practice.
If you are unable to make your scheduled appointment, please call our office at least 24 hours in advance. We will make every attempt to reschedule you into a slot that is convenient for you and your doctor based upon the urgency of the appointment.
I have read the above stated financial policy and agree to meet my
Controlled Substance Contract
Controlled substance medications (i.e. narcotics, tranquilizers, and barbiturates) are very useful, but have a high potential for misuse and are, therefore, closely controlled by local, state, and federal governments. They are intended to relieve pain, thus improving function, and/or ability to work.
Because my provider is prescribing controlled substance medications to help manage my pain, I agree to the following:
I have been fully informed by my provider regarding psychological dependence (addiction) of controlled substance medications. I know that some individuals may develop a tolerance to the medications, necessitating a dose increase to achieve desired effect, and doing so increases the risk of becoming physically dependent on the medication. This may occur if I am on the medication for several weeks. Therefore, when I need to stop taking the medication, I must do so slowly and under medical supervision, or I may have withdrawal symptoms.
2500 W. William Cannon Drive, Suite 401
Austin, Texas 78745
PH: 512-451-1969 FX: 512-458-2327
AUTHORIZATION FOR RELEASE OF INFORMATION
. Complete medical records
. Records of care from (Date of Service)
. Confer with another person orally about information in my record.
Contact telephone number:
Reason for Release:
(Article 4495 b, Sec. 5.08 (j) Texas Civil Statutes requires that an authorization for release of medical records include “the reason or purpose for the release.”)
Records Sent TO:
Physician / Person / Facility Name
Southwest Orthopaedic Group
2500 W William Cannon, Ste. 401
City / State / Zip
Austin, Texas 78745
I understand that the information released is for the specific purpose stated above. Any other use of this information without the written consent of the patient is prohibited.
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the individual or organization releasing the information. I understand that therevocation will not apply to information already released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization expires automatically in one year.
I understand that my medical record may contain reports, test results, and notes that only a physician can interpret. I understand and have been advised that I should contact my physician regarding the entries made in my medical record to prevent my misunderstanding of the information contained in these entries. I will not hold Southwest Orthopaedic Group liable for the misinterpretation of the information in my medical record as a result of not consulting with my physician for the correct interpretation.
(Patient or person legally authorized to consent on patient’s behalf. If not patient, state the relationship to the patient and the reason patient is unable to sign.