AUSZ03 Test Patient Information

Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Chart

Age

Today's Date

Date

FINANCIAL POLICY
In order to reduce confusion and misunderstanding between
our patients and the practice, we have adopted the following financial policy.
If you have questions, please discuss them with our billing staff or office manager. We are dedicated to providing the best possible care and service to you and regard your complete understanding of our financial policies as an essential element of your care and treatment.

Payment is due at the time of service unless other arrangements have been made in advance by either yourself or your health coverage carrier. For your convenience, we will accept cash, check and most major credit cards.
Your insurance is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor, in other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will look to you for payment. If we later receive a checkfrom your insurer, we will refund any overpayment to you.
We have made prior arrangements with many insurers and other health plans to accept an assignment of benefits. If you are covered by one of these plans, we will bill your plan and will only require you to pay the co-payment at the time of service.
All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be “not covered”, you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.
We will bill your health plan for all services provided in the hospital. Any balance remaining after your health plan pays is your responsibility. Payment is due upon receipt of a statement from our office.
A surgery deposit will be required prior to your surgery date. We will estimate the surgeon’s fees, not covered services, as well as the expected payment from your insurance company to determine the deposit amount. After your insurance company has paid our office and the actual patient responsibility is calculated you will be billed for amounts due or refunded amounts that you have overpaid. PLEASE NOTE THAT THIS ESTIMATE DOES NOT INCLUDE CHARGES FROM THE HOSPITAL, SURGERY CENTER, ANESTHESIA, PATHOLOGY, RADIOLOGY, LAB, ETC. YOU WILL RECEIVE SEPARATE BILLS FROM THESE ENTITIES FOR THEIR SERVICES
We will look to the adult accompanying a minor for all services rendered to minor patients.
Most surgeries include a 10-90 day period of covered postoperative office visits known as the “Global Period” as established by your health plan. This does not include x-rays, physical therapy, or durable medical equipment that may be prescribed. If you have a balance on your account, you will receive a total of three statements. Should your account become more than 90 days past due, your account will be sent to a collection agency.

I have read and understand the financial policy of the practice,
and I agree to be bound by its terms.
I also understand and agree that such terms may be amended
from time to time by the practice.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *

WORKER'S COMP DISCLOSURE

If you are seeking care at this facility for an injury/condition that occurred due to work, please note that we are required by the Texas Worker’s Compensation law to handle your claim with your employer’s workers compensation insurance carrier (pursuant to TWCC Rule 120.1 & 120.0). Please mark the applicable statement: *

I certify that my injury/condition IS work related

I certify that my injury/condition is NOT work related

PATIENT INFORMATION

***All sections MUST be completed. If not applicable, plase indicate as "N/A"***

Patient Name *

First Name

Middle Name

Last Name

Nickname

Date of Birth *

Date

Age

Sex

Marital Status

Single

Married

Widowed

Divorced

Social Security Number

Driver's License License State and Number

Permanent Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Home Phone Number

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Work Phone Number

Please enter a valid phone number.

Email

example@example.com

Preferred Language

Race

Decline

Asian

African American

Caucasian

Native American

Ethnicity

Decline

Hispanic or Latino

Non Hispanic or Latino

Smoking Status

Current Smoker

Former Smoker

Non Smoker

Start Date

Stop Date

Occupation

Employer/School Name

Primary Care / Family Physician's Name

Pharmacy Name

Phone Number

Please enter a valid phone number.

Address or Intersection

Have you been treated by one of our physicians?

Yes

No

If yes, by which doctor and the approximate date

Was your injury sustained on the job?

Yes

No

Has a claim been filed with your employer?

Yes

No

Referred By

If referred by a physician, what is their name?

First Name

Last Name

Emergency Contact

Relationship to the patient

I authorize Austin Sports Medicine to release treatment/account information to the following people

MEDICAL INSURANCE INFORMATION

***Complete with insured's information***

Primary Insurance

Insured's Name

First Name

Last Name

Date of Birth

Date

Social Security Number

Relationship to patient

Claims Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

ID #

Group #

Employer

Please attach a photo of the FRONT side of your primary insurance card.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Please attach a photo of the BACK side of your primary insurance card.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Secondary Insurance

Insured's Name

First Name

Last Name

Date of Birth

Date

Social Security Number

Relationship to patient

Claims Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

ID #

Group #

Employer

Please attach a photo of the FRONT side of your secondary insurance card.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Please attach a photo of the BACK side of your secondary insurance card.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)