Alliance
10932 N. Riverside Dr. #108
Fort Worth, TX 76244
817-540-4477
Sara E. Suttle, D.P.M.
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. Please arrive 15 minutes prior to your appointment time if you have
not completed your forms. Thank you in advance for your time. We look forward
to seeing you in the office.
1.
New Patient Packet
Consent/HIPAA/Disclosure/Financial Release
Forms 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 Sara Suttle, D.P.M.
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 Practicespolicy 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.
SIG
NATURE 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.
Than
k 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 Sara E. Suttle, D.P.M., of Texas Orthopedic Specialists, PLLC has a
financial interest.
Signature Date
Texas Health Harris Methodist Southlake Hospital
1545 E Southlake Blvd.
Southlake, TX 76092
Ph. (817) 748-8700
Office Use Only: Patient ID # Date: / /
Sara Suttle, D.P.M. - PATIENT QUESTIONNAIRE
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
Obstructive Sleep Apnea Blood Clots
Other:
PAST SURGERIES (List with approximate age, including all minor surgeries):
Surgery:
Date:
Physician:
FAMILY HISTORY (
List the relationship of family member next to applicable heath issue):
Bleeding:
Diabetes:
Amputations:
Cancer:
Tuberculosis:
Heart Disease:
Strokes:
High Blood
Pressure:
Other:
Seizure Disorder
SOCIAL HISTORY:
Employer:___________________________________________________ Job Description:_________________________________________________________
Recreational Activities/Exercise:____________________________________________________________________________________________________
Single:_______ Married:_______ Divorced:________ Widow:_________ No. Living Children:__________ No. of pregnancies:_________
Do you smoke: Y_____ N _______ Approx. amount/day:________ Have you ever smoked:_________________________________________
Do you drink alcoholic beverages?: Y_____ N _____ Type:______________ Approx. amount: ________ Daily / Weekly /
Monthly Recreational Drugs:_____________________________________________________________
Do you vape? Y______ N_______ Frequency: ____________________________________
Do you see a pain management physician? Yes No If yes, physician name:________________________________________
Do you have a pain management contract? Yes No Do you have a living will? Yes No
Do you have a medical power of attorney? Yes No
Date: / /
Name: DOB: - -
School/AT:________________________ Home Phone:________________________ Work:______________________ Cell:_____________________________________
Primary Care Doctor:
Last Visit with PCP:
Who referred you:
SHOE SIZE: __________________________________HEIGHT:__________________ WEIGHT:_______________________
__________________________________________________________________________________________________________________________________________________
*Type: I / II Dialysis: Yes / No Last HbA1C:________________ Blood Sugar this morning:______________
Medication List
Medication List:
Current Medications
Dosage (mg’s per day)
Please list any medication ALLERGIES you have:
Allergy
Type of Reaction
Do you have allergies to: Iodine_____ IV Contrast______ Tape/Adhesive: _____X-ray Dye_____ Latex_____ Jewelry/Metal:_____
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
Preferred Pharmacy:______________________________________________ Pharmacy Phone:______________________________________
Name:____________________________________________ DOB:___________________________
PAIN DIAGRAM AND PATIENT PROBLEM INFORMATION
NAME:__________________________________ DOB:____________________________ DATE:_________________________
Please use the diagram below to indicate the location of the
symptoms you are experiencing.
Describe the manner in which you were injured, and/or the details of the problem(s) you wish
to be seen for today. Please be as detailed as possible.
DATE OF INJURY: _________________________________________________________________________________________________
NATURE: (sharp/dull/achy/burning/etc.) ______________________________________________________________________
LOCATION: (where is the pain/problem?
) ______________________________________________________________________
DURATION: (how long have you had the problem?) ___________________________________________________________
ONSET: (what happened? new shoes/new activity/accident):________________________________________________
COURSE: (worsening/improving/intermittent) _________________________________________________________________
AGGREVATING FACTORS: (what makes pain/symptoms worse) _____________________________________________
TREATMENTS: (what have you done for treatment already and has it helped?/seen other doctors?) :
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
STAFF USE ONLY
PAIN SCALE:
LEFT: _______/10
RIGHT: _______/10
XRAYS TODAY: Y N
VIEWS: _____________
PREVIOUS XR: Y N
PREVIOUS AI: Y N
REFERRAL:_____________
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.