NEW PATIENT REGISTRATION FORM

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NEW PATIENT REGISTRATION FORM

Legal Name:

Last First Middle Preferred

Home Address:

Street Apt# City/ST/Zip

Phone(s): Home: Cell: Work:

Email: DOB: Age: DL#:

Gender: M or F Marital Status: Single Married Divorced Widow SS#

Employer Name: Employer Address:

Street City/ST/Zip

Employer Phone#: Occupation:

How did you hear about us?

Primary Care Doctor: Doctor Phone#:

PRIMARY INSURANCE INFORMATION: ( FILL IN INSURANCE INFORMATION BELOW OR CHECK BOX IF COPY OF CARD WAS PROVIDED)

Name of Primary Policy Holder: Relationship to Patient:

As It Appears On Card

DOB: Insurance Company: Insurance Phone#:

Policy ID#: Group#:

MEDICARE SUPPLEMENTAL INSURANCE INFORMATION:

Name of Primary Policy Holder: Policy ID/Group#:_

As It Appears On Card

RESPONSIBLE PARTY INFORMATION: ( CHECK IF SAME AS ABOVE)

Name: Address:

DOB: SS#: Phone#:_ Relationship to Patient:

EMERGENCY CONTACT/LEGAL GUARDIAN:

Name: Phone#: Relationship to Patient:

RELEASE OF INFORMATION AND ASSIGNMENTS OF BENEFITS: I hereby authorize the above-named agency to release my treatment information requested by attorneys, physicians, insurance companies, employers, healthcare providers or any other entity which may be concerned with the payment of charges incurred for the treatment of services of Plano Orthopedic Sports Medicine & Spine Center, P.A., and hereby authorize payment directly to Plano Orthopedic Sports Medicine & Spine Center, P.A. for services rendered. I accept responsibility for payment of any charges not paid for or accepted by my insurance. This authorization remains valid and effective from the date of signing until revoked in writing.

Signature of Patient or Legal Guardian Date

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Clinic Financial, HIPAA & Privacy Policies, Consent to Treat

PLEASE INITIAL ALL SECTIONS, SIGN & DATE FORM

FINANCIAL RESPONSIBILITY AGREEMENT:

Initials

I agree to assign insurance benefits to Plano Orthopedic Sports Medicine & Spine Center, P.A. We bill all insurance companies that we are contracted with as “network” providers as a courtesy to our patients.

I acknowledge full financial responsibility for services rendered by Plano Orthopedic Sports Medicine & Spine Center, P.A. and authorize transfer of all unpaid amounts to me, which includes, but is not limited to, Co-pays, Deductibles, Co-Insurance, Pre- existing Clauses, excluded conditions and/or termination of coverage. I agree to pay all legal fees including a ttorney and court fees as well as collection costs in the event of default payment of charges that are my financial responsibility. I further autho rize and request all insurance payments be made directly to Plano Orthopedic Sports Medicine & Spine Center, P.A.

PATIENT PRIVACY PRACTICES:

Initials

We are committed to ensuring your Protected Health Information (PHI) remains confidential. Your paper and electronic medical records are safeguarded and released only with your consent or to your insurance carrier, other medical professionals directly involved with your care, or as required by law. Our “Notice of Privacy Practices” policy manual, which explains how your medical information may be used and disclosed, is available for your review or you are welcome to have a copy. If you would like to release your PHI to another doctor or facility you will be required to fill out a separate form to request your records.

HIPAA & RELEASE OF INFORMATON:

Initials

I hereby authorize Plano Orthopedics Sports Medicine & Spine Center, P.A. to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment and other health care operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Plano Orthopedics Sports Medicine &

Spine Center, P.A. can refuse to see me. I have been provided with access to either review and/or receive a copy of “Notice of Privacy Practices” for Plano Orthopedic Sports Medicine & Spine Center, P.A. which more fully describes the uses and disclosures, and I understand that I have the right to review such “notice” prior to signing this consent. I understand I can revoke this consent at any time by notifying Plano Orthopedics Sports Medicine & Spine Center, P.A. in writing. I understand Plano Orthopedics Sports Medicine & Spine Center, P.A. has the right to change its privacy policies and that I can receive such changed notices upon r equest.

I understand that I have the right to request that Plano Orthopedics Sports Medicine & Spine Center, P.A. restrict how my individually identifiable health information is used and/or disclosed to carry out treatment, payment, or other healthcare operations. I understand that Plano Orthopedics Sports Medicine & Spine Center, P.A. does not have to agree to such restrictions, but that once such restrictions are agreed to, Plano Orthopedics Sports Medicine & Spine Center, P.A. must adhere to such restrictions.

RELEASE OF MEDICAL INFORMATION AUTHORIZATION:

Initials

I give Plano Orthopedics Sports Medicine & Spine Center, P.A. authorization for the release of “Medical Records/Privacy Infor mation”, which includes your PHI, any medical conditions and/or billing and financial information to the following:

Name: Relationship to Patient: _

CONSENT OF TREATMENT:

Initials

I authorize Plano Orthopedics Sports Medicine & Spine Center, P.A. Physicians and the Physician’s Assistants to evaluate and treat me or my family member for any orthopedic illness or injury for which I seek medical care. I have read and understand the above clinic polices and I further acknowledge that I accept the terms outlined in each of the above policies.

MEDICATION POLICY CONSENT:

Initials

I authorize Plano Orthopedics Sports Medicine & Spine Center, P.A. Physicians and the Physician’s Assistants to obtain a medication history and/or list of current medications via my pharmacy for medical records.

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PA-C CONSENT, POSMC DISCLOSURE

PHYSICIAN ASSISTANT CONSENT Initials

This facility has on staff Certified Physician Assistants (PA-C) to assist in the delivery of orthopedic medical care. I acknowledge a Physician Assistant is not a physician. A PA-C is licensed by the state medical board and under the supervision of a physician can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. “Supervision” does NOT require constant physical presence of the supervising physician, but rather overseeing and accepting responsibility for t he medical services provided. A list of services may be provided that are within the scope of practice for a PA-C upon request. I hereby acknowledge the above information and consent to the services of a Certified Physician Assistant for my health care ne eds. I understand that at any given time I can request to see the Physician instead of the PA-C.

DISCLOSURE OF FINANCIAL INTEREST Initials

Plano Orthopedic Sports Medicine & Spine Center, P.A. physician you are seeing may have a financial inter est in the facilities listed below. The facilities and our physicians are committed to providing clinical excellence in a safe and attractive environment for you and your family members. Their financial interest in these facilities enables them to have a voice in administration and the ir policies.

This involvement helps to ensure the highest quality of care for you. Should you have any concerns regarding this notice, please ask your physician or a member of the staff. My initials above verify that I have read and understand the above statement and information.

Baylor Medical Center at Frisco 5601 Warren Pkwy

Frisco, TX 75034 214-407-5000

Plano Therapy Center 3405 Midway Ste 500

Plano, TX 75093 972-473-0229 Texas Health Center for Diagnostic & Surgery

6020 W Parker Rd Plano, TX 75093

972-403-2700

Allen Therapy Center 1223 W McDermott Ste 50

Allen, TX 75013 972-359-1288 Methodist Hospital for Surgery

17101 N Dallas Pkwy Addison, TX 75001

469-248-3900

North Star MRI (Frisco) 8501 Wade Blvd Ste 220

Frisco, TX 75034 214-618-3420 Surgery Center of Plano

1620 Coit Road Plano, TX 75075

972-519-1100

North Star MRI (Plano) 3700 W 15^thSt Bldg D Ste 200

Plano, TX 75075 972-758-9000 Preston Plaza Surgery Center

17950 Preston Rd Ste 75 Dallas, TX 75252

972-267-5400

North Star MRI (Allen) 997 Raintree Circle Ste 110

Allen, TX 75013 972-954-8001 Baylor SurgiCare North Garland

7150 N. President George Bush Hwy Garland, TX 75044

(214) 703-1800

 Dr. Stephen Courtney, a POSMC physician also has a financial interest in Eminent Spine, a company that manufactures and designs spinal implants. Eminent Spine & Eminent Extremity 7200 N. IH 35 Bldg #1  Georgetown, TX 78626  512-868-5980

 Dr. John E. McGarry, a POSMC physician also has a financial interest in T5 Ortho, a company that distributes medical products.

ACKNOWLEDGEMENT:

 I acknowledge that I received access to the “Notice of Privacy Practices” information for Plano Orthopedics Sport Medicine &

Spine Center, P.A. I have read and understand the “HIPAA & Release of Medical Information Policy”.

 I hereby authorize Plano Orthopedic Sports Medicine & Spine Center, P.A. to release any information requested by the insurance company or companies or respective representatives and act as my agent to secure payment from any and all services rendered.

 I understand that I am financially responsible to the physician for any and all charges incurred by myself and/or dependents.

 I have read and understand the “Physician’s Consent” and the “Disclosure of Financial Interest”

 I further acknowledge and understand that I accept the terms outlined in each of the policies.

X

Patient or Guardian Signature Date

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UNIVERSAL CONDITION, INJURY/ACCIDENT STATEMENT FORM

ALL BOXES MUST BE COMPLETED BEFORE SEEING A PHYSICIAN

PATIENT NAME: TODAY’S DATE:

/ /

PLEASE COMPLETE THE FOLLOWING STATEMENTS. MOST INSURANCE COMPANIES REQUEST ACCIDENT DETAILS. THIS INFORMATION MAY BE FORWARDED WITH YOUR INSURANCE CLAIM OR PROVIDED TO AN ADJUSTER TO COMPLETE YOUR CLAIM.

WE MUST HAVE “BOX 1: CONDITION OR DATE OF INJURY” COMPLETED TO FILE YOUR CLAIM.

1. Please check: CONDITION INJURY INJURY DATE: / /

(ON OR ABOUT)

THIS DATE IS REQUIRED FOR INSURANCE FILING

How did the injury or pain occur, what were you doing?

(Brief Summary)

2. Did the injury occur during work? YES NO 3. Were you clocked in? YES NO

4. Were you at lunch? YES NO

THIRD PARTY LIABILITY

5. Is there a possible third party liability? YES NO

(INJURY OCCURRED SOMEWHERE OTHER THAN HOME OR WORK? SUCH AS AUTO, HOMEOWNER’S PROPERTY, ETC.?)

IF YES, A letter of subrogation should be provided before seeing the physician. Your health insurance will deny the claim if the letter is not obtained.

I certify that this information to be true and accurate. I hereby authorize the release of a copy of this form as may be nec essary to obtain reimbursement from any insurance company which may request information regarding my injury or condition and the na ture of my treatment. I also understand that I am responsible for responding promptly to my insurance carrier if they request any ad ditional information, and that failure to provide requested information may categorize my treatment as a “non-covered” service and may make me personally liable for the charges incurred.

SIGNATURE: TODAY’S DATE:

/ /

(RESPONSIBLE PARTY)

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Patient Name: Height: Weight:

Race:

^African American  Asian  Caucasian  Native American/Alaskan  Pacific Islander  Other

 Unknown  Decline to Answer

Ethnicity:

^ Hispanic  Non-Hispanic  Unknown  Decline to Answer

Preferred Language:

 English  Spanish  Chinese  Other

Preferred Pharmacy: Pharmacy Phone Referral Source:

Doctor (name): Other (ex. Google search):

Chief Complaint

Dominant Hand:

 Right  Left  Ambidextrous

Description of Symptoms:

(select only ONE primary symptom)

 Pain  Numbness/Tingling  Fracture  Stiffness Other:

Shoulder  Right  Left Pelvis  Right  Left Neck 

Upper Arm  Right  Left Hip  Right  Left Upper Back ^

Elbow  Right  Left Thigh  Right  Left Mid Back ^

Forearm  Right  Left Knee  Right  Left Low Back 

Wrist  Right  Left Lower Leg  Right  Left Buttocks 

Hand  Right  Left Ankle  Right  Left Tail Bone ^

Thumb  Right  Left Foot  Right  Left

Index  Right  Left Great Toe  Right  Left Middle  Right  Left 2nd Digit  Right  Left Ring  Right  Left 3rd Digit  Right  Left Little  Right  Left 4th Digit  Right  Left 5th Digit  Right  Left

Pain radiates from/to:

(ex. from low back to right leg)

History of Present Illness

1. Is your problem the result of an injury or accident?

 No Injury  Injury  Injury at Work  Auto Accident  Sport Injury  Prior Surgery

How long have the symptoms been present?

(ex. 2 days, 4 months)

Describe the onset:

 Acute (sudden)  Chronic condition (>3 months)

Onset Date:

(mm/dd/yyyy)

2. Are you represented by an attorney?

 Yes  No

Attorney Name:

Will there be any legal actions with respect to this problem?

 Yes  No

3. Have you had a problem like this before?

 Yes  No

Describe:

4. Have you been seen in an ER for this problem?

 Yes  No

Treating ER:

Date:

(mm/dd/yyyy)

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Patient Name:

Page 2

History of Present Illness (continued) 5. Rate the pain (10 being the most pain):

 0  1  2  3  4  5  6  7  8  9  10

6. Do the symptoms wake you from sleep?

 Yes  No

7. Please describe the symptoms:

 Sharp  Dull  Stabbing  Throbbing  Aching  Burning  Shooting

8. What is the timing of the symptoms?

 Constant  Intermittent (comes and goes)

9. Is the problem getting better or worse?

 Getting better  Getting worse  Unchanged

10. What makes the symptoms worse?

 Squatting  Kneeling  Sitting  Bending  Stairs  Twisting  Moving  Lying in bed  Running  Walking  Athletics  Standing  Gripping  Lifting  Reaching Overhead

11. Are there any other symptoms associated with this problem?

 Redness  Bruising  Swelling  Numbness  Stiffness  Limping  Clicking

 Locking  Popping  Tingling  Weakness  Giving way

Prior Testing / Treatment

Have you had any prior tests for this problem?

 None  X-rays  MRI  CT Scan  Nerve Test (EMG/NCV)  Bone Scan

Have you had any prior treatment for this problem?

 Yes  No

Type of treatment Status of symptoms after treatment (select only those that apply) Date of treatment

Ice  Improved  Worsened  Unchanged

Heat  Improved  Worsened  Unchanged

Rest  Improved  Worsened  Unchanged

NSAIDs  Improved  Worsened  Unchanged

Muscle Relaxers  Improved  Worsened  Unchanged

Chiropractor  Improved  Worsened  Unchanged

Physical Therapy  Improved  Worsened  Unchanged

Home Exercise Program  Improved  Worsened  Unchanged

Surgery  Improved  Worsened  Unchanged

Injections  Improved  Worsened  Unchanged

Bracing  Improved  Worsened  Unchanged

TENS unit  Improved  Worsened  Unchanged

Other/Comments:

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Patient Name:

Review of Systems

Please indicate if you have experienced any of the following symptoms in the last 6 months?

None Comments

1) GI  Heartburn, Ulcers  Nausea, Vomiting  Blood in Stool ^

2) ENDO  Fever  Heat or Cold Intolerance  Night Sweats 

3) CON  Weight Loss  Loss of Appetite  Fatigue ^

4) EYE  Blurred Vision  Double Vision  Vision Loss ^

5) ENT  Hearing Loss  Hoarseness  Trouble Swallowing ^

6) CV  Chest Pain  Palpitations 

7) RS  Chronic Cough  Pneumonia  Shortness of Breath 

8) GU  Painful Urination  Blood in Urine  Kidney Problems ^ 9) SK  Frequent Rashes  Skin Ulcers  Lumps  Psoriasis  10) NEU ^Frequent Falls  Loss of Coordination  Numbness



 Change in Bowel  Change in Bladder  Dizziness

11) PSY  Depression/Anxiety  Drug/Alcohol Addiction  Sleep Disorder 

12) HEM  Easy Bleeding  Easy Bruising  Anemia 

Select all previous hospitalizations/surgeries:

^

None

 Aneurysm (Brain) Surgery  Hysterectomy

 Aortic Bypass / Vascular Surgery  LAP Band / Gastric Bypass

 Appendectomy  Lumpectomy

 Cataract (Eye) Surgery  Mastectomy

 Cholecystectomy (Gallbladder)  Malignancy/Cancer

 Heart Surgery  Stents

 Hernia Repair

Other Surgery Other Orthopedic Surgery

Orthopedic on side: Right Left

Arthroscopy: Knee ^ ^

Arthroscopy: Shoulder  

Carpal Tunnel Release ^ ^

Rotator Cuff Repair ^ ^

Total Hip Replacement  

Total Knee Replacement ^ ^

Total Shoulder Replacement ^ ^ Spinal Surgery - Indicate Level:

Medical Questions

Mark all that currently apply:

 Metal in body  Claustrophobic  Pregnant  Sleep Apnea  Uses a CPAP  Snores

Are you taking blood thinners?

 Yes  No

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Patient Name:

Pain Diagram Social History

Do you use tobacco?

 Current, every day  Current, some day  Former tobacco use  Never

Do you drink alcohol?

 Daily  Occasionally  Rarely  Never

Marital Status:

^ Married  Single  Divorced

^ Widowed  Domestic Partnership

Are you currently working?

 Yes  No  Retired  Disabled If no, what date did you last work?

_______________

Please list work restrictions, if any:

______________________________________________________________________

Occupation:

____________________________

Employer:

_________________________ 

Student Family History

Have any direct relatives had any of the following disorders?

Father

^^None ^^Diabetes ^ Heart Disease  Hypertension

 Bleeding Problems  Epilepsy  Connective Tissue  Muscular Dystrophy

 Stroke  Osteoporosis  Rheumatoid Arthritis  Cancer Comments (ex. cancer type)

Mother

Sibling

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Page 5

Patient Name:

Please list all medications you take on a regular basis:

^

None

Medication Dosage and Frequency (e.g. 20 mg, once/day) Do you have any allergies?

^ Yes  No If Yes, please list below:

Medication, Relevant Food Reaction

Latex allergy?

 Yes  No

Do you have a personal history of any of the following?

^

None

 Aneurysm Where:  Emphysema  Kidney Disease

 Angina (Chest Pain)  Epilepsy  Kidney Stones

 Arthritis Type:  Heart Attack  MRSA Infection

 Asthma  Hepatitis Type:  Pacemaker

 Bone or Joint Infections  HIV / AIDS  Phlebitis (Blood Clots)

 Cancer Type:  High Cholesterol  Pulmonary Embolism

 Chemotherapy / Radiation  Hypertension  Reaction to Anesthesia Type:

 COPD  Hyperthyroidism  Seizures

 Congestive Heart Failure  Hypothyroidism  Stomach Ulcers

 Diabetes Type: Last A1C:  Stroke / TIA

 Tuberculosis