Patient Registration Form Patient Information First Name: Middle Name: Last Name: Date Of Birth: Social Security #: Sex: MaleFemale Address: City: State: Zip: Home Phone: Cell Phone: Email Address: Preferred Language: Marital Status: Currently living in a Skilled Nursing Facility? If Yes: Name: Phone Number: Address: City: State: Zip Code: Referring Physician (REQUIRED FIELD) Referring Physician: and Primary Care Physician: None Preferred Pharmacy (REQUIRED FIELD) If you do NOT have a pharmacy, please choose one today. Name: Phone Number: Address: City: State: Zip Code: Interpretation Services Do you need an Interpreter for your visits with us?: YesNo If YES, Please state: Hearing ImpairedLanguage In Case of Emergency: Emergency Contact First Name: Last: Cell: Secondary Phone: Relationship to patient: Billing Information : If Guarantor is not patient, please provide additional contact below. Name of person responsible for Bill: Address: City: State: Zip Code: Social Security #: D O.B. Primary Phone: Employer Name: Phone: Insurance Information Primary Insurance Carrier: Telephone #: Address on Back of Card: City: State: Zip Code: Secondary Insurance Carrier: Telephone #: Address on Back of Card: City: State: Zip Code: Is your visit due to: Work Related InjuryAuto AccidentPersonal Injury Date of Injury: Please briefly describe what brings you in today? Past Surgical and Medical History Please List All Past Surgeries And Dates: Surgery Detail Date Surgery Detail Date Surgery Detail Date Surgery Detail Date Surgery Detail Date Surgery Detail Date Surgery Detail Date Please List ALL Current Medications: Medicine Strength Dosage Medicine Strength Dosage Medicine Strength Dosage Medicine Strength Dosage Medicine Strength Dosage Medicine Strength Dosage Medicine Strength Dosage Medicine Strength Dosage Medicine Strength Dosage Medicine Strength Dosage Drug Allergies: Please List all Medications You Are Allergic to: Name Reaction Name Reaction Name Reaction Name Reaction Past Medical History: Please Check All items that Apply: AnemiaColon/IntestinalHepatitisMigrainesSeizures/ EpilepsyAsthmaCOPDHiatalHerniaMitral ValveProlapseSleep ApneaBlood ClotsCubital TunnelHigh CholesterolPacemaker/DefibrillatorStent PlacementBreastDiabetesHypertensionPancreatitisStomachBronchitisEmphysemaHypoglycemiaPneumoniaStrokeBunionsGallbladder JaundicePolioThyroid ProblemsCancerGoutKidney DiseaseProstate DiseaseCarpal TunnelHeart AttackLiver Disease Rheumatoid ArthritisColitisHeart DiseaseMental IllnessRotator Cuff Injury Other Are you being seen by a Cardiologist? YesNo If Yes, by whom? Date Of Last Visit Have you ever had an adverse reaction to anesthesia? YesNo If yes, please describe: Orthopaedic and Systems Screen: Please CHECK all items that apply Constitutional: Weight GainWeight LossFeverNight SweatsExercise Intolerance Eyes: IrritationDrynessChange in Vision ENMT: Difficulty hearingEar PainNosebleedsSinus ProblemsSnoringSore ThroatBleeding GumsDry MouthMouth UlcersOral AbnormalitiesTeeth Problems Cardiovascular: Shortness of Breath PalpitationsChest Pain Arm PainHeart Murmur Respiratory: CoughWheezingShortness of BreathCoughing up Blood Gastrointestinal: VomitingDiarrheaAbdominal PainLoss of AppetiteVomiting Blood Genitourinary: IncontinenceHematuria Difficulty UrinatingUrination Frequency Musculoskeletal: Muscle AchesWeaknessArthralgiaJoint PainBack PainSwelling Integumentary: JaundiceRashesMoles Neurologic: WeaknessNumbnessSeizuresHeadachesLoss of Consciousness Psychiatric: DepressionSleep DisturbanceAlcohol Abuse Endocrine: FatigueWeight GainWeight Loss Hematologic/Lymphatic: BruisingSwollen Glands Allergic/Immunologic: ItchingHivesRunny NoseSinus PressureFrequent Sneezing Social History Do you Smoke? YesNo Former Smoker: YesNo If Yes, How many packs per week? Years of use: Do You Drink Alcohol? YesNo If yes please circle what applies below: RarelyDailyAlcoholicSociallyWeeklyRecoveringAlcoholic Drug Use? NeverPastCurrently Work Status: EmployedUnemployedLight DutyFull DutyRetired Family History: Please Write Immediate Family member that has had indications below: Diabetes High Blood Pressure Heart Disease Low Blood Pressure Vascular Disease Cancer Bleeding Disorders High Cholesterol Women Only: Are you pregnant? YesNo If Yes, Due Date: 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. Signature ( Patient or Patient Representative ) Date Patient Refusal to Sign / Employee Date Who may we give information to regarding your condition, treatment, or diagnosis? Name Phone Relationship Is there anyone who should never have this information: Name Phone Relationship Please list the contact phone numbers where we are able to contact you: Place Phone Number Able to Leave a Message? Home Answering Machine or Service Work Cell Phone May we send you emails related to patient information or appointments? YesNo Email Address I give SWOG permission to obtain my 2 year medication history from SureScripts. Please sign and date below: Signature ( Patient or Patient Representative ) Date Financial Policies 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: I understand that I am responsible for any remaining balance not covered by my insurance company. Due to the large volume of missed appointments, we now require 24 hours notice if you need to cancel an appointment. If you miss an appointment or cancel an appointment without giving 24 hours notice you will be charged a $25 missed appointment fee. an appointment. If you miss an appointment or cancel an appointment without giving 24 hours notice you will be charged a $25 missed appointment fee. If you have to schedule surgery, we require 24 hours advanced cancellation notice. There will be a $150 charge for surgeries that are cancelled with less than 24 business hours notice. If your surgery is scheduled for less than 24 hrs out, we will review your situation case-by-case. you will be charged a $25 missed appointment fee. We refer delinquent accounts to an outside collection agency. If it became necessary to refer your account to a collection agency, an administrative service fee of $25 plus a collection fee of 30% of your balance will be assessed to your account. Our office charges a $25 administration fee for FMLA paperwork, Short-term disability paperwork, and any requests for medical records that are under 25 pages. There will be an additional charge of $.50 per page over 25 pages. Payment is due in advance and please allow 48 business hours for processing. Our office charges a $25 administration fee for NSF / Returned Checks per occurrence. We will reserve the right to no longer accept checks made to your account. 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 Signature ( Patient or Patient Representative ) Date 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 am responsible for the controlled substance medications prescribed to me. If my prescriptions are misplaced, stolen, or if I “run out early”, I understand that this medication will not be replaced regardless of the circumstances. Refills of controlled substance medications; “run out early”, I understand that this medication will not be replaced regardless of the circumstances. a) will only be made during regular office hours, Monday through Friday, in person, once a month, and during a scheduled office visit. Refills will not be made at night, weekends, or during holidays. b) will not be written for more than a 10 day period without refills. c) will not be made if “I lost my prescription”, ran out early, or misplaced my medication. I am solely responsible for taking the medication as prescribed and for keeping track of the remaining. d) I understand that I must call ahead within 72 hours to schedule an appointment. It may be deemed necessary by my doctor that I see a medication-use specialist (pain management) at the time and during the time that I am receiving controlled substance medications. I understand that if I do not attend such an appointment, my medications may be discontinued, or may not be refilled beyond tapering dose completion. I understand that if the specialist feels that I am at risk for psychological dependence (addiction), my medications will no longer be filled. I understand that if I violate any of the above conditions, my prescriptions for controlled medications may be terminated immediately. If the violation involves obtaining these medications from another individual, or the concomitant use of non-prescription illicit (illegal) drugs, I may also be reported to other physicians, pharmacies, medical facilities, and the appropriate authorities. I understand that the main treatment goal is to reduce pain, and improve my ability to function and/or work. In consideration of this goal, and the fact that I am being given potent medication to reach my goal, I agree to help myself by following better health habits, exercise, weight control, and avoidance of the use of tobacco and alcohol. I must also comply with the treatment plan as prescribed by my physician. I understand that the long term advantages and disadvantages of chronic opioid use may have yet to be scientifically determined and my treatment may change at any time. I understand, accept and agree that there may be unknown risks associated with the long term use of controlled substances that my physician will advise me of advances in the field and will make necessary treatment changes. I further understand that if I violate this controlled substance contract due to non-compliance of medical directions, such as, failure in taking medications as prescribed, utilizing other illicit drugs, or abuse of controlled medications, I may be subject to dismissal from this facility. 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. Signature - Patient Date Signature – Provider Date 2500 W. William Cannon Drive, Suite 401 Austin, Texas 78745 PH: 512-451-1969 FX: 512-458-2327 AUTHORIZATION FOR RELEASE OF INFORMATION Records requested: . Complete medical records . Records of care from (Date of Service) Date From To only . Other (please specify) . Confer with another person orally about information in my record. Name Date of Birth Contact telephone number: I understand that the information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. YES, I consent to the release of this information.NO, I do not consent to the release of this information. 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.”) Change of PhysicianPatient RelocationDisability ClaimWorkers’ Compensation ClaimApplication for Insurance CoverageConsult w/ another physician for conditionOther: Records Requested FROM: Physician / Person / Facility Name Address City / State / Zip Records Sent TO: Physician / Person / Facility Name Southwest Orthopaedic Group Address 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 Name (Please Print): Date of Birth: Social Security #: Patient’s Signature: (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.
