texas institute of orthopedic surgery & sports medicine · texas institute of orthopedic...

Texas Institute of Orthopedic Surgery & Sports Medicine

Patient Information

Last Name: First Name:

Preferred Name: Marital Status: Single Married Other

Date of Birth: Social Security #________________________ Sex: Male Female

Address: Primary Doctor:

City: State: Zip: Referring Doctor:

Home # Work # Cell #

How did you hear about us? Patient/Parent Email:

Emergency Contact Name: Relationship:


Please select the description you closely identify with in each category

Racial Category Language Ethnicity

American Indian or Alaska Native Pacific Islander English Hispanic/Latino

Black or African American Asian Spanish Non-Hispanic/Latino

White or Caucasian Hispanic Other Refused to Report

Other Refused to Report

Responsible Party (If patient is a minor or has a legal guardian)


Date of Birth: Social Security #________________________

Address: City: State: Zip:


Pharmacy Information

Pharmacy Name:

Pharmacy Address:

City: State: Zip:

Phone # Fax #

Worker’s Compensation ***Did this injury occur at your job location? Yes No***

Date of Injury: Claim#

Employer Name:


Employer Contact: Phone # Fax#

Adjuster’s Name: Phone # Fax#

Primary Insurance OR Worker’s Compensation Insurance

Insurance Company Name:

Claims Address:

City: State: Zip: Phone#

Policy # Group #

Employer Name: Phone #


Who is the primary insured party? Patient Responsible Party Other (complete below)


Date of Birth: Social Security #



Patient’s Relation to Insured Spouse Child Other

Secondary Insurance

Insurance Company Name:

Claims Address:

City: State: Zip: Phone#

Policy # Group #

Employer Name: Phone #


Who is the secondary insured party? Patient Responsible Party Other (complete below)


Date of Birth: Social Security #



Patient’s Relation to Insured Spouse Child Other

Medicare Patients

Are you a resident of a Skilled Nursing Facility or Rehab Facility Admit Date:

Name of Facility: Phone #

Facility Address:

City: State: Zip:

Patient’s Printed Name Date of Birth

Signature of Patient, Parent, or Legal Guardian Date

Texas Institute of Orthopedic Surgery & Sports Medicine, PLLC

ePrescribing: This office, as a government requirement, utilizes electronic prescriptions. I authorize Texas Institute of Orthopedic Surgery and Sports Medicine, PLLC to check my medication history. By refusing to sign this consent I understand a prescription (if recommended) will not be provided to me.

Signature: ______________________________________ Date: _________________

Consents and Disclosures: I hereby voluntarily agree to diagnostic procedures, medical and surgical treatment

which may be performed on me under the general or special instructions of the attending provider’s care and

service or the provider’s designee(s). I further understand that the practice of medicine and surgery is not an

exact science and that diagnosis and treatment may invoke risks. No guarantees have been made to me as to the

results of my treatment at Texas Institute of Orthopedic Surgery and Sports Medicine, PLLC. I understand that

Texas Institute of Orthopedic Surgery and Sports Medicine, PLLC encourages me to ask questions and voice

concerns about medical care or services and that asking questions or voicing concerns will not compromise my

care. (I understand any invasive procedure will be explained and I will be asked to sign an authorization for that

treatment.) This consent is valid for each visit I make to Texas Institute of Orthopedic Surgery and Sports

Medicine, PLLC unless revoked by me orally or in writing.

Surgical Facility Interest Disclosure: Should it be determined that surgery is required, a facility, Baylor Medical

Center at Trophy Club, Reliant Rehabilitation Hospital – Mid-Cities and Ethicus Hospital – Grapevine, is made

available to you. However, Dr. Wenger has ownership interest in Baylor Medical Center at Trophy Club and Dr.

Khan and Dr. Khubchandani would like you to know that they have ownership interest in these facilities and if

imaging is required Dr. Khan and Dr. Khubchandani have ownership interest in Preferred Imaging. If you do not

wish to use them, for any reason, we will be happy to schedule your surgery or imaging at another facility.

Please be informed Texas law allows a patient to be tested for possible exposure to the Human

Immunodeficiency Virus (HIV), the virus associated with AIDS, in the following situations: 1) to screen

blood, blood products, organs or tissues to determine suitability for donation; 2) if another individual is

accidentally exposed to patient’s blood or body fluids, such as through a needlestick (any such test shall be

conducted pursuant to Texas Institute of Orthopedic Surgery and Sports Medicine, PLLC’s infectious

disease protocol); or 3) if a medical or surgical procedure is to be performed which could expose health

care workers to the patient’s blood or body fluids. This disclosure is to inform you that you may be tested,

at the expense of Texas Institute of Orthopedic Surgery and Sports Medicine, PLLC if any of these

situations occur during your treatment period.

By signing below, I certify that I have read this agreement and/or that it has been fully explained to me, that I

understand its contents, and that I am the patient, or a person duly authorized to execute this agreement and

accept its terms.




Assignment of Benefits Form

Financial Responsibility

All professional services rendered are charged to the patient and are due at the time of service, unless other

arrangements have been made in advance with our business office. Necessary forms will be completed to file for

insurance carrier payments.

Assignment of Benefits

I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby

authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical

plan, to issue payment check(s) directly to Texas Institute of Orthopedic Surgery and Sports Medicine, PLLC

medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I

understand that I am responsible for any amount not covered by insurance.

Authorization to Release Information

I hereby authorize Texas Institute of Orthopedic Surgery and Sports Medicine, PLLC to: (1) release any information

necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the

course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance

claims for the period of a lifetime. This order will remain in effect until revoked by me in writing.

I have requested medical services from Texas Institute of Orthopedic Surgery and Sports Medicine, PLLC on behalf

of myself and/or my dependents, and understand that by making this request, I become fully financially

responsible for any and all charges incurred in the course of the treatment authorized.

I further understand that fees are due and payable on the date that services are rendered and agree to pay all

charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this

assignment is to be considered as valid as the original.



Relationship to Patient


Patient Financial Policy

Thank you for choosing Texas Institute of Orthopedic Surgery and Sports Medicine, PLLC as your health care

provider. We are committed to providing excellent health care services to you, our patient. As a part of our

professional relationship, it is important that you have understanding of your insurance benefits and our financial

policy.

Patients must read and sign this form prior to receiving services.

We are providers for many managed care plans. We will file claims for those plans we participate in, and

will require you to pay your copay/deductible/coinsurance at the time of the visit. Please be advised, if we

have not heard from your insurance company within 60 days, the balance will become the patient’s

responsibility.

We must emphasize that, as a medical provider, our relationship is with you, the patient, and not your

insurance company. Your insurance is a contract between you, your insurance company, and possibly your

employer. It is your responsibility to know and understand the level of services covered by your insurance

company.

Not all services are medically necessary. Some insurance companies arbitrarily select services they will not

cover. You are responsible for these services.

Any services provided, in addition to the office visit, such as x-rays, injections, durable medical equipment,

physical therapy, etc. may be applied to your deductible and/or coinsurance and not fall under an office

visit copayment. If you are unsure about your insurance coverage, please ask to speak to our billing

specialist so that we can inform you of the information received from your insurance company at the time

of verification. If you require an estimate prior to us preforming any services, please do not hesitate to ask.

Any imaging services, such as MRIs, are billed outside of this office by the imaging company. We forward

your demographic and insurance information to the imaging facility who in turn will bill you directly for

any additional imaging services.

We may accept assignment of insurance after verification of your coverage. Please be aware that some of

or perhaps all of the services provided may not be covered in full by your insurance company. You are

financially responsible for services not covered by your insurance company.

We make every effort to help you with your referral from your primary care physician (if one is required),

however it is the patient/guardian’s responsibility to confirm that we have a current referral. Physicians

are permitted to treat ONLY the condition(s) listed on the referral.

We will file Medicare and a secondary or supplemental policy. You will receive a bill for any services

approved by Medicare, but not paid by your secondary or supplemental plan. This is true also for other

primary and secondary insurances.

We are NOT providers for MEDICAID.

Additional fees are charged for the following:

o No Show Appointment $25.00

o Completion of Forms $25.00/form

o Copy of X-Ray on CD $10.00

Failure to keep your account balance current may require us to cancel or reschedule your appointment.

Full payment is due at the time of service. We accept cash, check, and credit cards (Visa, MasterCard, & Discover).

I have read, understand and agree to this policy.





HIPAA Form

Acknowledgement of Receipt of Notice of Privacy Practices

I have been provided with a Notice of Privacy Practices that provides me a more complete description of the uses

and disclosures of certain health information. I understand the Texas Institute of Orthopedic Surgery and Sports

Medicine, PLLC reserves the right to change their Notice of Privacy Practices and prior to implementation will

provide an updated copy on the office website, www.tiosonline.net, and in the physician’s office. I may request a

copy of the updated Notice of Privacy Practices by calling my physician’s office or requesting a copy in person at

my appointment.

I want a copy I do not want a copy

The following names are of people I would like to be involved in or have access to my protected health

information on a routine basis. I gave permission for Texas Institute of Orthopedic Surgery and Sports Medicine,

PLLC to share my protected health information with:

1.) Relationship: Phone#

Contact’s Date of Birth: (required for identification purposes only)

2.) Relationship: Phone#

Contact’s Date of Birth: (required for identification purposes only)




Telephone Contact

May we leave messages on your answering machine regarding your care? Yes No

(Please understand that if we cannot leave messages, it will be your responsibility to initiate contact with

us regarding follow up of labs, appointments, etc.)

Do you consent to receive autodialed, prerecorded, or text messages to your phone that serve to remind you of

an upcoming appointment? Yes No



Release of Medical Records

I hereby authorize Texas Institute of Orthopedic Surgery and Sports Medicine, PLLC to send or obtain any medical

information needed for my care.

I understand that the specific information to be released may include all physician records as well as treatment of

drug or alcohol abuse, mental illness, or communicable disease. This does include Human Immunodeficiency

Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). I also understand that this authorization may be

revoked by the person giving authorization by written and dated notice, except to the extent that disclosure of

information had been made prior.

You have a right to limit medical information we disclose to someone involved in your care, if you wish to do so

please write down any persons or facilities that you do not want to receive information and the information that

you want limited. Please note that Texas Institute of Orthopedic Surgery and Sports Medicine, PLLC does not have

to agree to your request.

You may revoke this authorization at any time in writing, except where information has already been

released.

A photocopy or fax of this authorization is as valid as this original.

Information used or disclosed pursuant to the authorization may be subject to disclosure by the recipient

and may no longer be protected by this rule.

Restriction List




815 Ira E Woods Ave Ste 100 • Grapevine, Texas 76051

Ph: 817-421-0505 • Fax: 817-421-6060

Physician Ownership Disclosure

To further our commitment to the quality of care for our patients, Dr’s Amir Khan, Zubin Khubchandani, Scott Wenger &

Scott Hrnack have chosen to be owners at Baylor Medical Center at Trophy Club, Ethicus Hospital (Khan & Khubchandani

only), Preferred Imaging-Grapevine, ESA Labs and the Physical Therapy department here at TiOS (Texas Institute of

Orthopedic Surgery and Sports Medicine, PLLC). Baylor Medical Center at Trophy Club, a partnership between Baylor

Healthcare and local physicians, and Ethicus Hospital meet the Federal definition of a physician owned hospital. Our

ownership enhances our ability to direct the manner in which your care is delivered at the facility. If this is of concern to

you, we will be happy to answer any questions. You have the option to have surgery, other healthcare services, laboratory

testing, imaging or therapy performed at the facility of your choice. We will be happy to discuss your options of choosing an

alternative location.

I acknowledge that I have the right to choose the provider of my healthcare services and I have chosen Baylor Medical

Center at Trophy Club, Ethicus Hospital, Preferred Imaging-Grapevine, ESA Labs and/or Physical Therapy at TiOS.

Signature of Patient/Personal Representative:

Relationship: ____________________________________________________

Date: ______________________

Amir M. Khan, M.D., P.A.

Board Certified in Orthopedic Surgery Board

Certified in Orthopedic Sports Medicine

Fellowship in Sports Medicine & Arthroscopy

Fellowship in Foot & Ankle

Zubin G. Khubchandani, M.D.,

P.A.

Board Certified in Orthopedic Surgery

Board Certified in Orthopedic Sports Medicine

Fellowship in Sports Medicine & Arthroscopy

Scott A. Wenger, M.D., PLLC


Fellowship in Sports Medicine &

Arthroscopy

Scott A. Hrnack, M.D., PLLC


Fellowship in Sports Medicine &

Orthopedics

Texas Institute of Orthopedic Surgery & Sports Medicine, PLLC 815 Ira E. Woods Ave., Suite 100, Grapevine, TX 76051

Ph: (817)421-0505 Fax: (817)421-6060, www.tiosonline.net

PLEASE COMPLETE ALL SECTIONS History & Physical

Name Date

Primary Care Doctor: Who referred you here?

Age Height inches Weight lbs. Circle: Are you RIGHT or LEFT handed?

Did this injury occur at your job location? Yes or No Is this due to an auto accident? Yes or No

If yes please inform the receptionist.

Current injury/problem details

Reason for visit Date problem began:

How injury or problem occurred:

By whom were you seen? What tests did What meds did What splint or brace

(Check all that apply) you have? you use? did you use?

PCP None None

PA at PCP’s office X-rays Advil

Urgent care center CT Aleve

ER CTA Ibuprofen

Baylor Grapevine ER MRI Meloxicam

TCMC ER MRA Celebrex

THR Alliance ER U/S Tylenol

THR HEB ER Bone Scan Hydrocodone

THR Southlake ER Blood Test Ultram

Las Colinas ER EMG/NCV OTC NSAID’s OTC=over-the-counter

Where is If pain radiates to If pain radiates to Describe Rate

the pain? RIGHT, then where? LEFT, then where? pain? pain? Fingers Back Fingers Back None 0

Hand Buttock Hand Buttock Nonspecific 1

Wrist Groin Wrist Groin Achy 2

Forearm Hip Forearm Hip Burning 3

Elbow Thigh Elbow Thigh Dull 4

Arm Knee Arm Knee Electric 5

Shoulder Leg Shoulder Leg Pins/Needles 6

Sh. Blade Ankle Sh. Blade Ankle Pressure-like 7

Chest Heel Chest Heel Sharp 8

Neck Foot Neck Foot Stabbing 9

Head Toes Head Toes Throbbing 10

Frequency of pain? Timing of the pain?

Rare Biweekly During cold weather At midday

Intermittent Monthly During warm weather At end of day

Frequent Yearly When awake When active

Constant Unpredictable When asleep When resting

Daily Predictable In the mornings At work

Weekly At night

Please CHECK all that apply to you below:

Pain is Pain is Other symptoms Do you have? Do you have?

alleviated by: aggravated by: (Yes) (No) (Yes) (No) (Yes) (No)

None None Catching Neck pain Fevers __

Rest Certain activities Deformity Back pain Chills __

Immobilization Any activity Giving out Upper back pain Nausea __

Laying Lifting Instability Bowel Incontinence Vomiting __

Meds Overhead work Locking Bladder Incontinence Chest pain __

Resting Repetitive hand use Painful ROM UE numbness or tingling SOB __

Sitting Running Popping UE weakness/paralysis Calf Pain __

Standing Sitting Stiffness LE numbness or tingling Calf Swelling __

Sleeping Stairs Swelling LE weakness/paralysis Bloody Stools __

Therapy Sleeping Mass Gait Disturbance GI ulcers __

Walking Walking None Head Injury LOC __ UE = upper extremity

LE = lower extremity

What’s your functionality now? Back to normal Much improved Improved Unchanged Worse Much worse

Rate it: 0-10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70-80% 80-90% >90% Normal

List medical history: Including conditions being treated with medications or write in none.

List past surgeries & dates: or write in none.

List current meds & doses: or write in none.

List drug allergies: or write in none.

Are you allergic to latex? Yes or No Contrast dye? Yes or No Tape? Yes or No

List Family medical history: or write in none. Father: Mother:

Sister(s): Brother(s):

Other important history in the family:

List Social History:. Do you smoke? YES or NO, How many Packs/day? How many years have you smoked? Do you

drink? YES or NO, How many Drinks/day? How many days per week?

Drug use? YES or NO, If yes circle: RECREATIONAL, DRUG ADDICTIONS, CHRONIC PAIN CONTROL

Review of body systems: Please Check YES or NO for each item

Yes No Yes No

GENERAL: EYES AND EARS:

Fever/Chills Glasses/contacts __

Fatigue Vision loss __

Recent Weight gain Ringing in ears __

Recent Weight loss Hearing loss __

NOSE AND THROAT: CARDIOVASCULAR:

Sinus infections Chest pain __

Nose bleeds Irregular rhythm __

Mouth lesions Poor circulation __

Dentures/braces Ankle swelling __

GASTROINTESTINAL: RESPIRATORY:

Heartburn Asthma __

Ulcers Allergies __

Nausea/vomit Short of breath __

Diarrhea Cough __

MUSCULOSKELETAL: NEUROLOGICAL:

Joint pains Faint/blackouts __

Joint swelling Poor coordination __

Joint stiffness Weakness __

Gait problems Numbness __

SKIN-INTEGUMENTARY: PSYCHIATRIC:

Rash Depression __

Itching Anxiety __

Skin cancer Substance dependence __

GENITOURINARY: ALLERGY/IMMUNOLOGY:

Kidney disease Dust/pollen __

Incontinence Food __

Urinary infections Hay fever __

HEME-ONCOLOGY: ENDOCRINE:

Anemia Always thirsty __

Easy bruising Increased appetite __

Blood clots Heat/cold sensitivity __

Please list any additional information in this space:

__ Signature of Patient, Parent, Date Physician Signature Date or Legal Guardian

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