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Benjamin T. Drury, M.D. (Texas Orthopedic Specialists)

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Benjamin T. Drury, M.D.
Mid-Cities
2425 Highway 121
Bedford, TX 76021
817-540-4477
Dear Patient,
The following forms need to be filled out before you come to your
appointment. Filling out these forms completely and accurately will
expedite the registration process. Please also ensure all items listed
are brought with you to your appointment. Thank you in advance for
your time. We look forward to seeing you in the office.
1.
New Patient Packet
Consent/HIPAA/Financial Release
Form Required Government Form
2.
Physician Questionnaire
3.
Insurance Card and form of identification
4.
Any surgical x-rays/MRI films and MRI report done within the last 6
months
5.
A Copay/deductible will be collected at the time of visit. If you do
not have insurance coverage, payment in full is expected prior to
each visit.
Sincerely,
The staff of Benjamin T. Drury, M.D.
Alliance
10932 N. Riverside Dr. #108
Fort Worth, TX 76244
817-540-4477
P
LEASE INITIAL ALL SECTIONS, SIGN & DATE FORM
FINANCIAL RESPONSIBILITYAGREEMENT:
Initials
I agree to assign insurance benefits to Texas Orthopedic Specialists, PLLC. 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 Texas Orthopedic Specialists, PLLC 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 attorney and court fees as well as collection costs in the
event of default payment of charges that are my financial responsibility. I further authorize and request all insurance payments be made directly to
Texas Orthopedic Specialists, PLLC. Payment is expected at the time of service. We will file your insurance as a courtesy to you. If your deductible has
not been met and/or if you are responsible for a co-payment under your plan, we will expect the payment of such upon delivery of services and
immediately upon the end of your visit. There will be a $30 fee for returned checks.
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.
CONSENT OF TREATMENT:
Initials
I authorize Texas Orthopedic Specialists 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.
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 the 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
PA for my health care needs. I understand that at any given time I can request to see the Physician instead of the PA-C.
PROOF AND CHANGE OF INSURANCE
Initials
Patient are required to show both proof of insurance and a Government issued photo ID at their initial and subsequent visits. The patient (parent/legal
guardian) is responsible for informing our office of any changes in your insurance coverage since your last visit. Please assure that notification is made no
later than 24 hours prior to your appointment to avoid having to re-schedule your appointment.
DISABILITY PAPERWORK/ MISSED APPOINTMENT POLICY/ RADIOLOGY AND LAB FEES
Initials
Please give all forms regarding disability to the nursing staff. Please do not give these forms to the physician. Please note that there is a $25.00 completion
fee per form. You will need to expect 72 hours for these forms to be completed. Fill out the portion of the disability form that is for the patient and leave
physician areas blank.
We must be notified at least 24 hours in advance of an appointment cancellation/need to reschedule. A $50 fee may be charged for a no show or late
cancellation of appointments. Payment of this fee is the responsibility of the patient and is not covered by insurance.
You may incur additional charges from providers outside of your network for procedures done outside of our facility that may be part of your surgical
procedure or radiological exam. This can include pathology, radiology and/or lab fees.
ACKNOWLEDGEMENT:
•
I acknowledge that I received access to the “Notice of Privacy Practices” information for Texas Orthopedic Specialists, PLLC I have read and understand the
“HIPAA & Release of Medical Information Policy”.
•
I hereby authorize Texas Orthopedic Specialists, PLLC 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.
•
I understand that no warranty or guarantee has been made to me relative to result of care or medical outcome.
•
This authorization remains valid and effective from the date of signing until revoked in writing.
X
Patient or Guardian Signature
Date
X
Patient or Guardian Printed Name
Patient ID - Office Use Only
□
□
□
□
□
□
□
□
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected
health information. Texas Orthopedic Specialists must obtain a signed authorization from the patient or the patient’s legally authorized
representative to electronically disclose the patient’s protected health information. Individuals cannot be denied treatment based on a failure
to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits.
Patient Name:_______________________________________________ Date of Birth:_________________________
I HEREBY AUTHORIZE TEXAS ORTHOPEDIC SPECIALISTS TO DISCLOSE THE PATIENT’S PROTECTED
HEALTH INFORMATION TO THE FOLLOWING PERSON/ORGANIZATION:
1.
Person / Organization Name:
Address:
Phone: Fax Number
2.
Person / Organization Name:
Address:
Phone: Fax Number
REASON FOR DISCLOSURE (Choose One): Treatment / Continuing Medical Care Personal Use Billing or Claims
Insurance Legal Purposes Disability Determination School Employment Other
WHAT INFORMATION CAN BE DISCLOSED: Complete the following by indicating those items that you want
disclosed. The signature of a minor patient is required for the release of some of these items. If all health information is to be
released, then simply check the appropriate spot:
___ All Health Information ___ Pathology Reports
___ Operation Reports ___ Billing Information
___ Lab Results ___ Radiology Reports/Images
___ Diagnostic Test Results ___ Other: ___________________________
RIGHT TO REVOKE: I understand that I can withdraw permission at any time by giving written notice stating my intent to revoke this
authorization. I understand that prior actions taken by Texas Orthopedic Specialists and other entities that had permission to access my
protected health information in reliance on this authorization will not be affected by such revocation.
SI
GNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand
that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise
permitted by law without my specific authorization or permission, including disclosures by covered entities. I understand that information
disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state
privacy laws. In addition, I hereby authorize Texas Orthopedic Specialists to leave detailed messages for me regarding appointments,
prescriptions, or any other information pertinent to my medical care, on any phone number that I have provided.
This authorization remains valid and effective from the date of signing until revoked in writing.
X Date:
Signature of Patient or Legally Authorized Representative
Printed Name of Legally Authorized Representative of Patient (if applicable):
If representative, specify relationship to patient:
____ Parent of Minor
____ Guardian
____ Other
Medication Policy and
Disclosure of Financial Interest
Medication Refill Policy;
1. For refills on medication please call between:
Monday - Thursday 8:30 - 4:00pm
2. Please call several days before your supply of medication runs out. This allows adequate time to have your prescription refilled, as
it’s important to understand this CANNOT be considered an emergency for our staff.
3. We request that you use the same pharmacy for all your prescriptions and use only one physician to obtain pain medications.
Please allow 24 hours to process a prescription refill request and understand medications are refilled on a patient by patient basis and
never refilled over the weekends or after normal business hours.
Thank
you in advance for acknowledging and following our simple medication policy.
Signature Date
Disclosure of Financial Interest:
A Texas Orthopedic Specialists, PLLC physician you are seeing may have a financial interest 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 their 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 signature below acknowledges that I understand
that my plan of care may include admission to any of the below facilities, in which B. Todd Drury, M.D., of Texas Orthopedic Specialists, PLLC has a
financial interest.
Signature Date
Bear Creek Surgery Center
100 Bourland RD. Suite 110
Keller, TX 76248
Ph: (817) 518-9130
Texas Health Harris Methodist Southlake Hospital
1545 E Southlake Blvd.
Southlake, TX 76092
Ph. (817) 748-8700
Office Use Only: Patient ID # Date: / /
Benjamin T. Drury, M.D. - PATIENT QUESTIONNAIRE
Date: / /
Name: DOB: - -
Family Physician:___________________________________________________________________ Phone #:________________________________________________
Referring Physician: Phone #:
Body part you are being seen for?:
Place of Injury/Accident:_____________________________________________ Date of Injury/Accident:__________________________________________
Any Pending/potential litigation involved with the injury? ____Y _____N
How did the injury occur?: (please be as
detailed as possible, including where you were and what happened when injury
was sustained):
____________________________________________________________________________________________________________________________________________________
Age: ____________ Sex: _____M _____F Martial Status: _____Married _____Single _____Divorced Height:__________ Weight:_____________
Work Related: ______ Y _______N Work: _____Full-time _______ Full-time Limited ________Part-time _________Self Employed
Employer:_______________________________________________________ Job Description:___________________________________________________________
Hand Dominance: _____Left ______Right Do you smoke or have you ever?: _____Y _____N Approx. amount/day:___________
Do you drink alcohol or have you ever?: _____Y _____N Approx. amount: ______________ Daily / Weekly / Monthly
Do you take illicit drugs or have you ever?: ______Y ______N If yes, what drugs:____________________________________
Seasonal Allergies: _____Y _____N Please circle when: Winter / Spring / Summer / Fall
Do you wear eyeglasses or contacts? (please circle): Eyeglasses / Contacts / None
If you brought Radiology films with you today, please indicate type of films brought:____________________________________________
Activity Quality of Life Limitation: ____________________________________________________________________________________________
Pain is made worse by?: ________________________________________________________________________________________________________
Are you (please circle): Improving / Unchanged / Worsening
Pain level (please rate from 1-10): ____________________ Explain:_____________________________________________________________
Associated Symptoms (circle all that apply):
Aching
Burning
Numbness
Tingling
Sharp Shooting
Throbbing
Dull
Deep
Tight
Other:
Review of symptoms in the past 6 weeks that you have experienced (please circle and explain):
Significant Weight
Loss or Gain
Fever or Chills
Light
headed/dizzy/
fainting
Headaches/
Migraines
Sore
Throat/Cough/
Runny Nose
Abdominal
Pain/Vomiting Blood
Chest
Pain/Shortness of
Breath
Painful Urination/
Blood in Stool
Swelling/
Skin Rash
Other:
PAST ILLNESSES (Circle all that apply):
None
DVT/Clots
Diabetes
Gastrointestinal Disease
Heart Disease
Cancer (localized - one area)
Hepatitis
HIV
Kidney Disease
Cancer (metastatic - spread)
Lung Disease
Stroke
Rheumatoid Arthritis
Infection in Any Joint
Cholesterol
Osteoarthritis
Thyroid
High Blood Pressure
Sleep Apnea
Blood Clots
Other:
School/AT:__________________________________ Home phone:________________________ Work:____________________ Cell:____________________________
Seizure Disorder
_____
______
_____
_____
_____
____
_____
FAMILY HISTORY (List the relationship of family member next to applicable health issue):
Bleeding:
Diabetes:
Amputations:
Cancer:
Tuberculosis:
Heart Disease:
Strokes:
High Blood
Pressure:
Other:
Medica
tion List:
Please list any medication ALLERGIES you have:
Allergy
Type of Reaction
Are you seeing a pain management physician? Yes No
If s
o who is your physician?___________________________________________
Do you have a pain management contract? Yes No
Preferred Pharmacy:_______________________________________ Pharmacy Phone:__________________________________
Do you have allergies to: Iodine IV Contrast Tape X-ray Dye Latex
Do you use a CPAP or Bi PAP Machine: Yes _ _ No
Notice of Medication and Pharmacy Benefit Management Consent:
Texas Orthopedic Specialists has the permission to obtain formulary information, information about other
prescriptions prescribed by other providers and/or third party pharmacy benefit payors for treatment
purposes.
_____________________________________________________________________________________ ___________________________________________
Signature Date
Current Medications
Dosage (mg’s per day)
_____
PAST SURGERIES (List with approximate age, including all minor surgeries):
Surgery: Date: Physician:
Do you have a living will? ____ Yes ____ No
Do you have a medical power of attorney? ____ Yes ____ No
www.txortho.net
DISCRIMINATION IS AGAINST THE LAW
Texas Orthopedic Specialists, P.L.L.C. (TOS) complies with applicable Federal civil rights laws and
does not discriminate on the basis of race, national origin, age, disability, or sex. TOS does not
exclude people or treat them differently because of race, national origin, age, disability, or sex.
TOS provides free aids and services to people with disabilities to communicate effectively with
us, such as qualified sign language interpreters.
TOS provides free language services to people whose primary language is not English, such as
information written in other languages.
Language services are available at the front desk at all of our locations.
If you believe that TOS has failed to provide these services or discriminated in another way on
the basis of race, national origin, age, disability, or sex, you can file a grievance with:
• Attention: TOS’s Compliance Officer
• Mailing Address: 2425 Hwy 121, Bedford, TX
• Fax: (817) 510-0059
• Email: pam@txortho.net
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance,
TOS’s Compliance Officer is available to help you.
You can also file a civil rights complaint with the U. S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/portal/lobby.jsf, or by mail or phone at: U. S.
Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH
Building, Washington, D.C., 20201. Phone 1-800-368-1019. (TDD) 1-800-537-7697.
Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html.
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Completed 16 June 2021

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