PLEASE INITIAL ALL SECTIONS, SIGN & DATE FORM
FINANCIAL RESPONSIBILITYAGREEMENT:
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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:
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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:
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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
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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
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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
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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:
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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”.
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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.
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I understand that I am financially responsible to the physician for any and all charges incurred by myself and/or dependents.
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I have read and understand the “Physician’s Consent” and the “Disclosure of Financial Interest”
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I further acknowledge and understand that I accept the terms outlined in each of the policies.
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I understand that no warranty or guarantee has been made to me relative to result of care or medical outcome.
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This authorization remains valid and effective from the date of signing until revoked in writing.
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Patient or Guardian Signature
Date
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Patient or Guardian Printed Name
Patient ID - Office Use Only
