New Patient Consent Form

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT

This form constitutes the Notice of Privacy Practices for The Methodist Hospital Physician Organization and its Physicians. This Notice describes your legal rights regarding your health information and will inform you of the legal duties and privacy practices of The Methodist Hospital Physician Organization and its Physicians with respect to health information created for services by your physician or other health care provider at a different location. You may want to ask about that office or clinic’s health information privacy policies and notices because they could be different.

Your name and signature below indicate that you have been provided with a copy of this Notice of Privacy Practices. Please do not hesitate to call The Methodist Hospital Physician Organization’s Business Practices Officer at: 713.383.5125.

Patient Name*

PrefixFirstLastSuffix

Date

Digital Signature*

Yes, I hereby signify that I am the patient named above.
I am the Patient's Qualified Personal Representative.

Name of Qualified Personal Representative

PrefixFirstLastSuffix

CONSENT TO TREAT

I voluntarily consent to the physicians and other clinical personnel of The Methodist Hospital, Department of Orthopedics, for the evaluation and treatment of the conditions for which I present myself to this office.

I acknowledge that I am legally responsible for all reasonable charges in connection with the medical care and treatment provided by representatives of The Methodist Hospital, Department of Orthopedics and promise to pay whatever charges are not paid by my health plan or insurance in return for the medical care and services that are provided to the patient.

I understand that this consent form will be valid and remain in effect as long as I receive my medical care at The Methodist Hospital, Department of Orthopedics. I understand that this consent may be revoked in writing at any time.

Patient Name*

PrefixFirstLastSuffix

Patient's Date of Birth*

Consent to Treat*

Yes, I hereby signify that I am the patient named above, and that the statements above are true.
I hereby signify that I am the Guarantor of the patient, who is a minor, and the statements above are true.

Name of Guarantor (if patient is a minor)

PrefixFirstLastSuffix

Date Signed

ASSIGNMENT OF BENEFITS

YOUR SIGNATURE IS NECESSARY FOR US TO PROCESS ANY INSURANCE CLAIMS AND TO ENSURE PAYMENT OF SERVICES RENDERED.

I hereby authorize my insurance benefits to be paid directly to The Methodist Hospital, Department of Orthopedics, realizing I am responsible to pay non-covered services. I certify that the information given by me to The Methodist Hospital, Department of Orthopedics, in applying for payment under insurance coverage or other protection is correct and complete. I authorize any holder of medical information about me, to release to the insurance company or its agents, any information needed to determine the benefits payable for related services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

I AGREE TO BE FINANCIALLY RESPONSIBLE FOR ALL CHARGES. I HAVE READ AND UNDERSTAND THIS INFORMATION.

Patient Name*

PrefixFirstLastSuffix

Confirmation of Assignment of Benefits*

Yes, I hereby signify that I am the patient named above, and that the statements above are true.
I hereby signify that I am the Guarantor of the patient, who is a minor, and the statements above are true.

Name of Guarantor (if patient is a minor)

PrefixFirstLastSuffix

Date Signed*

PERMISSION TO DISCLOSE RELEVANT HEALTH INFORMATION TO INDIVIDUALS INVOLVED IN MY HEALTH CARE

Check the appropriate statements below...*

I GIVE PERMISSION for Dr. David Lintner to disclose relevant health information (my health status, treatment, and payment arrangements) to my family members and to the individual(s) I have listed below who are involved in my health care.
I DO NOT GIVE PERMISSION for Dr. David Lintner to disclose relevant health information (my health status, treatment, and payment arrangements) to family members and other individuals involved in my health care.

Check the appropriate statements below...*

I GIVE PERMISSION for any surgery centers or hospitals associated with Dr. David Lintner’s practice to disclose relevant health information (my health status, treatment, and payment arrangements) to my family members and to the individual(s) I have listed below who are involved in my health care.
I DO NOT GIVE PERMISSION for any surgery centers or hospitals associated with Dr. David Lintner’s practice to disclose relevant health information (my health status, treatment, and payment arrangements) to family members and other individuals involved in my health care.

1. Name of Family Member or Other Individual

FirstLast

1. Relationship of the above-named family member or individual.

2. Name of Family Member or Other Individual

FirstLast

2. Relationship of the above-named family member or individual.

3. Name of Family Member or Other Individual

FirstLast

3. Relationship of the above-named family member or individual.

4. Name of Family Member or Other Individual

FirstLast

4. Relationship of the above-named family member or individual.

Patient's Name*

PrefixFirstLastSuffix

Date of Signature

Name of Witness*

PrefixFirstLastSuffix

Date of Signature

If other than patient...

Patient is a minor
Patient is unable to give permission because...

How old is the patient?

Please explain why the patient is unable to give his/her permission...

Name of Individual Signing on Behalf of Patient

PrefixFirstLastSuffix

Date of Signature

Phone

This field is for validation purposes and should be left unchanged.

Timmons Office: (713) 441-3560 (map)
Baytown Office: (832) 556-0880 (map)

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT

CONSENT TO TREAT

ASSIGNMENT OF BENEFITS

PERMISSION TO DISCLOSE RELEVANT HEALTH INFORMATION TO INDIVIDUALS INVOLVED IN MY HEALTH CARE

Sports injury? Injury related to other activity?

Dr. David Lintner

Pages in this Site

Most Recent Articles

Orthopedic Links

Rehabilitation

Sports Links

Timmons Office: (713) 441-3560 (map)
Baytown Office: (832) 556-0880 (map)

Timmons Office: (713) 441-3560 (map) Baytown Office: (832) 556-0880 (map)

New Patient Consent Form

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT

CONSENT TO TREAT

ASSIGNMENT OF BENEFITS

PERMISSION TO DISCLOSE RELEVANT HEALTH INFORMATION TO INDIVIDUALS INVOLVED IN MY HEALTH CARE

Sports injury? Injury related to other activity?

Dr. David Lintner

Pages in this Site

Most Recent Articles

Orthopedic Links

Rehabilitation

Sports Links

Timmons Office: (713) 441-3560 (map) Baytown Office: (832) 556-0880 (map)

Timmons Office: (713) 441-3560 (map)
Baytown Office: (832) 556-0880 (map)

Timmons Office: (713) 441-3560 (map)
Baytown Office: (832) 556-0880 (map)