Financial Policy Thank you for choosing us as your orthopaedic

Financial Policy Thank you for choosing us as your orthopaedic specialists. We are committed to providing you the best possible care & are pleased to discuss our professional fees with you at any time. The following is a statement of our Financial Policy which we require you to read and sign prior to any medical services. • FULL PAYMENT IS EXPECTED AT THE TIME OF SERVICE. • ALL PAYMENTS WILL BE COLLECTED UPON CHECKING IN FOR YOUR SCHEDULED APPOINTMENT. • WE ACCEPT CASH, PERSONAL CHECKS, VISA, AND MASTERCARD. INSURANCE • If we are a participating provider with your insurance plan you are responsible for all co‐payments deductibles and any non‐covered services at the time of service. As a courtesy we will file insurance claims with most insurance carriers, provided you have supplied us with the proper information. • If we are NOT a participating provider with your insurance plan you are responsible for full payment at time of service. If you need to file your own insurance our office will provide you with the proper documentation. • Bills for surgery will not include charges of anesthesia, hospitalization, or laboratory test. These are billed separately, from the facility where the surgery is performed. MINOR PATIENTS The adult parent or guardian accompanying the minor is responsible for payment of the minor patient’s account regardless of who the insurance policy holder is. For unaccompanied minors non‐emergency treatment can be denied until a parent or guardian is present or we have written permission for treatment and payment of the account period. WORKMAN’S COMPENSATION All workmen’s compensation claims must be verified in writing by the employer. Verbal or telephone verifications are not acceptable. If you have seen another physician for the same complaint an authorization for a change of physician must be verified on your company’s form. PERSONAL INJURY WITH ATTORNEY If you are being represented by an attorney or a third party payer, we will provide you with the proper information to file your claim. You are responsible for full payment to our office at the time services are rendered. AUTOMOBILE ACCIDENT If you were in an automobile accident and you have “Med‐Pay” automobile insurance our office will provide you with the proper documentation to file the claims. It will be your responsibility to file the claims. If you have health insurance we will file a claim for all professional services received. FORMS: We will be happy to complete any medical forms. Payment of $20.00 is required prior to completion of each form(s). Please allow 7‐10 business days for your form to be completed. We will notify you when the form is ready. MISSED APPOINTMENTS Failure to give 24 hour notice of cancellation of your appointment will result in a $25.00 fee billed directly to you. We will not bill your insurance company for this amount. You will be responsible for prompt payment of this fee prior to being seen at your next scheduled visit. COLLECTIONS If your account balance becomes past due and is sent to an outside collection agency, you will be responsible for any additional fees incurred. All monthly statements are due and payable in full upon receipt. All returned checks are subject to a $25.00 service fee. If you need to make special payment arrangements this needs to be brought to our attention prior to being examined. Your signature below indicates that I understand and agree to this financial policy. _________________________________________________ __________________________________ Signature of Patient or Guardian Date Prescription Refills
I agree that Wake Orthopaedics, LLC may request and use my prescription medication history from other healthcare
providers or third party pharmacy benefit payors for treatment purposes. I understand that Wake Orthopaedics, LLC
requires 48 hours to process my refill requests. Prescription refills will not be processed Saturdays, Sundays or
Holidays.
Patient or responsible Party
Signature ____________________________________________________________
Date ___________________
Capital City Surgery Center, LLC
I understand that during the course of my physician/patient relationship with the physician, the physician
may refer me to Capital City Surgery Center, LLC ("the Center"), which is an ambulatory surgery center
located at 23 Sunnybrook Road, Raleigh, North Carolina, 27610.
In connection with any such referral, the physician hereby advises you that such physician or one or more
physicians providing services to you at the Center may have an ownership interest in or other financial
relationship with the Center. Please be advised that you have the right to obtain the health care items and
services for which the physician refers you, at any location or from any ambulatory surgery center, hospital,
provider, or supplier of your choice, including the Center.
Patient or responsible Party
Signature ____________________________________________________________
Date ___________________
COMPOUND AUTHORIZATION
T
I have been asked whether I choose to designate other persons/entities to receive my health information. I do not choose to
designate such persons on the Compound Authorization form.
T
I give my permission to WakeMed Faculty Physicians to release listed information to the entities named below.
T Spouse / Significant Other (provide name): _______________________________________________________________
T Financial/billing Information
T Medical Information as follows:
T Labs*
T Appointments
T Diagnostic Tests*
T General medical information/condition
T Parent / Family Member or Other (specify relationship & provide name): ____________________________________________
T Financial/billing Information
T Medical Information as follows:
T Labs*
T Appointments
T Diagnostic Tests*
T General medical information/condition
T Employer / Workers' Compensation (provide name): _______________________________________________________
T Information about return to work and/or work restrictions, and any absences that result from appointments.
T School / Preschool / Day Care (provide name): ____________________________________________________________
T Information about any absences that result from appointments
T Activity Restrictions
T Physicals and/or Well-Child Examination
*Lab and diagnostic results will not be left on voice mail.
Rights of the Patient
I understand the medical information to be disclosed may include information regarding psychological or psychiatric impairment, a
communicable disease (such as sexually transmitted disease, HIV/AIDS, tuberculosis, or hepatitis), mental illness, alcohol or
substance abuse.
I understand that I have the right to revoke this authorization in writing at any time, except to the extent that the information has
already been released pursuant to this authorization. Otherwise, this authorization shall continue to be valid only for as long as
reasonably necessary to carry out the purposes listed above or one year, whichever is the earlier date.
I understand that treatment will not be conditioned upon my completion of this authorization.
I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
Patient/Representative Signature: ________________________________________________
Date: ________________
Witness: _____________________________________________________________
T Patient unable to sign
Please note that the information disclosed pursuant to this authorization may be subject to re-disclosure by a recipient of such
information and would no longer be protected under the terms of the federal privacy rule.
Revocation / Amendment
Name/Signature: _____________________________________________________________
Date: ________________
Staff Use Only: Compound Authorization Obtained By Telephone
Authorized Person Giving consent:: _____________________________________________________________________________
Telephone #: ___________________________
Relationship to patient: ______________________________________________
Witness: ____________________________ Witness: _________________________ Date: ___________ Time: __________
WakeMed Faculty Physicians
Compound Authorization
LABEL
REV. 9/07
WFP-104
AUTORIZACIÓN MIXTA
T
Se me preguntó si deseo designar a otras personas o agencias para que reciban información sobre mi salud. Yo no deseo
designar a tales personas en este formulario de Autorización Mixta.
T Le doy permiso a WakeMed Faculty Physicians para que comparta los datos listados a continuación con las personas o
agencias nombradas abajo.
T Esposo(a) u otra persona especial (indique el nombre): ____________________________________________________
T Información sobre cuentas y facturas
T Información médica, como sigue:
T Laboratorios
T Pruebas de diagnóstico
T Citas médicas
T Información médica/condición generalizada
T Padres u otro familiar (indique nombre y parentesco): _______________________________________________________
T Información sobre cuentas y facturas
T Información médica, como sigue:
T Laboratorios
T Pruebas de diagnóstico
T Citas médicas
T Información médica/condición generalizada
T Patrono o Seguro de Compensación para Empleados (indique nombre): _____________________________________
T Información sobre cuándo debe regresar al trabajo o restricciones de trabajo, y cualquier ausencia que resulte de las citas.
T Escuela, Párvulos o Guardería (indique nombre): _______________________________________________________________
T Información sobre cualquier ausencia causada por citas médicas
T Restricciones de actividades
T Exámenes físicos o de seguimiento de niño sano
*Resultados de pruebas de laboratorio y diagnóstico no se dejarán en contestadoras telefónicas.
Derechos del paciente
Entiendo que los datos médicos que se compartirán pueden incluir información relacionada con incapacitación psicológica o
psiquiátrica, enfermedades contagiosas (tal como enfermedades contagiadas sexualmente, VIH o SIDA, tuberculosis o hepatitis),
enfermedad mental, abuso de alcohol o drogas. Entiendo que tengo el derecho de revocar esta autorización en cualquier momento,
por escrito, con excepción de lo que ya se haya compartido de acuerdo a esta autorización. De lo contrario, la validez de esta
autorización continuará por el tiempo que sea razonablemente necesario para llevar a cabo los propósitos enumerados arriba, o por
un año, según lo que ocurra antes. Entiendo que mi tratamiento no dependerá de que yo dé o no esta autorización. Entiendo que
tengo el derecho de rehusar firmar esta autorización y que mi tratamiento no dependerá de si la firmo o no.
Firma del paciente o su representante: ________________________________________________
Fecha: ________________
Testigo: _________________________________________________________________________
T Paciente no puede firmar
Por favor note que la información compartida de acuerdo a esta autorización puede estar sujeta a que la misma sea compartida por
los que reciben la información de nuestra parte, y entonces ya no estará protegida bajo los términos de los requisitos federales de
privacidad.
Revocación o Cambios
Nombre y firma: __________________________________________________________________
Fecha: ________________
Staff Use Only: Compound Authorization Obtained By Telephone
Authorized Person Giving consent:: _____________________________________________________________________________
Telephone #: ___________________________
Witness: ____________________________
Relationship to patient: ______________________________________________
Witness: _________________________
Date: ___________
Time: __________
WakeMed Faculty Physicians
Compound Authorization
LABEL
REV. 9/07
WFP-104
Wake Orthopaedics PATIENT INFORMATION FORM First Name Street Address County Middle Initial Last Name City State Zip Code Email Address Home Phone Work Phone Date of Birth Age Social Security # ( ) ( ) Marital Status Gender Employer/School Name & Address Male Female Family Physician Referring Physician/Referral Source Person to Contact in Case of Emergency Relationship Spouse/Parent Name Social Security # Spouse/Parent Address City Phone Number ( ) Phone Number ( ) State Zip Code Problem Information Injured/ Painful Area: _______________ ( ) Right ( ) Left Date of Injury/Onset: __________ Medication Allergies: No ( ) Yes ( ) If “Yes” List Allergies____________________________ Was this a motor vehicle accident? If yes, provide name of Insurance Company Yes No Was this a work‐related injury? Employer at time of injury Yes No Please Complete Insurance Information Insurance Company Policy Number Subscriber’s Name Subscribers Social Security # & DOB Subscriber’s Employer Secondary Insurance Company Policy Number Subscriber’s Name Subscribers Social Security # & DOB AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT TO PAY PROVIDER DIRECTLY: I authorize the release of information to my referring or family physician and/or that which is necessary to file claims to the insurance carrier and the billing of my account for payment. I understand that you may be transmitting any records electronically, and I absolve all parties of any liability relating to such transmission of said records. I authorize my insurance carrier to make payment directly to Wake Orthopaedics, LLC. I understand that I am responsible for any remaining balance due on my account not covered by my insurance carrier. Thus, if the account balance is not satisfied within 30 days after the first notification, the account may be referred for legal action. I consent to the treatment rendered to me under the general/special care of the attending physician. Signature ____________________________________________________________ Date ___________________ New Patient History Form
FOR US TO PROCESS YOUR CHART, PLEASE COMPLETE FULLY AND PRINT CLEARLY
PATIENT NAME:
PRIMARY CARE DOCTOR:
REFERRING DOCTOR:
PATIENT D.O.B:
WHAT IS YOUR MAIN COMPLAINT?
SIDE
PLEASE CHECK SIDE AND BODY PART
Shoulder
Back
Foot / Ankle
(Circle One)
Right
Hand
Elbow
Hip
Knee
Finger (circle one)
Thumb Index Middle
Left
Fracture
Both
VITAL SIGNS:
Height:
Ring
Small Finger
Weight:
PAIN SCORE (0-10): _______
PAIN STATUS (circle one): (Improving)
(No Change)
(Worsening)
ALLERGIES:
 None
Allergy:_________________Allergy:__________________ Allergy:_________________Allergy:________________
Reaction: _______________Reaction:_________________ Reaction:________________Reaction:_______________
PHARMACY: _______________________
CURRENT MEDICATIONS AND DOSAGE:
 None (Please list on back if you need additional space)
_______________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
________________________
SUPPLEMENTS:
Fish Oil:
(Yes)
(No)
Gingko Biloba:
(Yes)
(No)
Vitamin D:
(Yes)
(No)
Calcium:
(Yes)
(No)
Glucosamine/Chondroitin:
(Yes)
(No)
PAST SURGICAL HISTORY: (Check All that Apply)
□All Negative
Achilles repair
Elbow Surgery
Arthroscopic knee surgery
Foot or ankle surgery
Arthroscopic shoulder
Hand or finger surgery
surgery
Back decompression
Hip or knee replacement
CABG
Hip surgery
Coronary stent
Neck fusion
PAST MEDICAL HISTORY: (Check All that Apply)
□All Negative
Anemia
Fracture-last 5 years?
Anxiety
GI Bleeding
Asthma
Gout
1
Open knee surgery
Open shoulder surgery
Pacemaker/defibrillator
Pelvic surgery
Wrist Surgery
Other:
Osteoporosis
Psoriasis
Pulmonary embolism
Blood Clots/DVT
Heart Attack
Rheumatoid arthritis
Bone Density Test Date:
Hepatitis (specify B or C)
Seizures
_________
Cancer
High Cholesterol
Staph infection
Cardiac arrhythmia
Hypertension
Stroke
Chemo/radiation
Kidney Disease
Thyroid Disease
Chronic steroid use?
MRSA
Ulcers (GI)
Depression
MSSA
Other:
Diabetes mellitus
Multiple Sclerosis
FAMILY MEDICAL HISTORY: (Check All that Apply) □All Negative
Condition
Relationship to
Condition
Relationship to Patient
Patient
Heart Disease
Diabetes
Lung Disease
Tuberculosis
Alzheimer’s Disease
Parkinson’s
Cancer
Multiple Sclerosis
Stroke
Osteoarthritis
Scoliosis
Rheumatoid Arthritis
Seizures
OTHER:
SOCIAL HISTORY
Alcohol Use (Circle One): (Yes) (No)
Drinks/Week:
_______ Glasses of Wine
_______ Cans of Beer
_______ Shots of Liquor
_______ Drinks containing 0.5 oz of alcohol
Drug Use:
(Circle One): (Yes) (No)
Frequency Per Week: _____________ Comments:_____________________________
Type(s): _____________________________
Tobacco Use:
(Circle One): (Current Everyday)
Packs/day (Circle One):
0.25
(Current Someday)
0.5
1.0
1.5
(Former)
2.0
3
(Never)
Other:_____________
Quit Date:________________
Smokeless Tobacco (Circle One):
(Current User)
(Former User)
(Never)
.
Quit Date:________________
OCCUPATION: ______________________________________________________________
FEMALE PATIENTS ONLY:
Are you pregnant, or is there a chance you may be pregnant?
REVIEW OF SYSTEMS: (Circle All that Apply OR Check All Negative Under Each Section)
□All Negative
Fever
Skin Rash
+
+
Chills
Shortness of breath
+
+
Wound drainage
Frequent Falls
+
+
Leg Swelling
Heart Murmur
+
+
Unexplained Weight
Other
+
+
Loss
2
(Yes)
(No)