New Patient Enrollment

Visit our website at www.TexasRegionalPhysicians.com/WeightLoss for more information and FAQs.

AUTHORIZATION FOR TREATMENT

I hereby consent to treatment by the attending physician and other medical staff for all local anesthetics, tests, surgical and other medical procedures as deemed necessary by myself and the medical staff.

AUTHORIZATION FOR RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS

I authorize Texas Regional Physicians – Urgent Care and Minor Emergency to submit claims and receive payment for services which maybe otherwise payable to me from all sources with whom I have contracted. I understand that I am financially responsible to Texas Regional Physicians – Urgent Care and Minor Emergency for charges not covered or paid by this assignment and will adhere to the financial policies of Texas Regional Physicians – Urgent Care and Minor Emergency in the collection of these charges. I accept full responsibility for providing claims for reimbursement of services. I authorize Texas Regional Physicians – Urgent Care and Minor Emergency to release any information necessary to insurance carriers or attorneys regarding illnesses and treatment necessary to process claims. I authorize the refund of overpaid insurance benefits where my coverage is subject to coordination of benefits. 

FINANCIAL POLICY

I fully understand that I am financially responsible for any and all amounts not otherwise paid by my insurance carrier.

I certify that the information about me to be released to the Health Care Finance Administration or other health care coverage entity, any information needed for this or any related health care claim in writing or verbally. I further understand and agree to pay for services or amounts due when appropriate. These charges could include amounts applied to my annual deductible co-payment amounts, and charges denied as not covered by my insurance program or deemed medically unnecessary. I understand that well care is not covered by Medicare or many other health insurance programs.

The following information is provided to avoid any misunderstanding concerning payment for professional services. All professional services rendered are charged to the patient. When supplied with complete insurance information, we will file your insurance for you. The patient is responsible for all fees regardless of insurance coverage. It is customary to pay for services when rendered unless prior arrangements have been made with our business office. We are participating providers with Medicare, therefore, claims will be filed by Texas Regional Physicians – Urgent Care and Minor Emergency and payment will be received at this office. A copy of this authorization and assignment shall be considered as valid as the original.

You understand that you are responsible for your account balance regardless of what any insurance pays. You hereby authorize Texas Regional Physicians – Urgent Care and Minor Emergency to furnish information to my insurance carrier and/or attorneys concerning my treatments. You hereby assign to Texas Regional Physicians – Urgent Care and Minor Emergency all payments for services rendered to myself and/or my dependents.

 

• All charges for treatment become due and payable within thirty (30) days after your insurance payer has evaluated and processed your claim at which time you are responsible for any remaining balance.
• The patient acknowledges that it is the patient’s responsibility to be aware of what services are covered and agrees to pay for any services deemed to be non-covered or not authorized by their plan(s).
• All payers – it is the patient’s responsibility to verify that we are participating providers with your health plan. In the event that we do not participate with your plan, we will file your claim as a courtesy but you will be responsible for full payment for services rendered at the time of the visit.
• We may charge you a “No Show” fee if you fail to cancel or reschedule your appointment at least 24 hours prior to your appointment date/time.
• Insufficient fees on returned checks will be $25.00.

 

CERTIFICATION, AUTHORIZATION AND RELEASE IN ACCORDANCE WITH HIPAA

The above-referenced patient (“Patient”) and Attorney of Record (“Attorney”) certify that the information provided in this Lien is correct and complete and acknowledge that this is a lien for Texas Regional Physicians – Urgent Care and Minor Emergency to secure payment for rendered medical-related services in connection to Patient’s personal injury claim. Patient understands that, in accordance with the Health Information Portability and Accountability Act of 1996 (“HIPAA”), Patient’s medical information relating to this personal injury claim may be shared to manage and expedite Patient’s medical diagnosis and treatment. Patient authorizes Patient’s physician, Attorney and Texas Regional Physicians – Urgent Care and Minor Emergency to secure, release and disclose such medical treatment information with companies and individuals deemed necessary, and further agrees that examinations, diagnoses, medical treatments, films, and reports can be shared with parties involved in patients claim by Texas Regional Physicians – Urgent Care and Minor Emergency. Attorney acknowledges and represents to Texas Regional Physicians – Urgent Care and Minor Emergency that Attorney has obtained a Release of Medical Information (“Release”) from Patient for purposes of communications regarding Patient’s medical information and that Texas Regional Physicians – Urgent Care and Minor Emergency is covered by such Release, and as a result Texas Regional Physicians – Urgent Care and Minor Emergency is authorized to receive and release such information.

ASSIGNMENT AND/OR LIEN FOR MEDICAL SERVICES

Patient understands that the medical services, supplies and treatment Patient is receiving as a part of the ongoing personal injury claim shall be billed as a lien, as authorized by applicable state law and practice. Patient hereby irrevocably authorizes and direct Attorney, to pay directly to Texas Regional Physicians – Urgent Care and Minor Emergency, such sums due and owing for services rendered to Patient by reason of the accident from which the claim arises, and by reason of any other bills that are due to Texas Regional Physicians – Urgent Care and Minor Emergency, and to withhold such sums from any claim, settlement, judgement or verdict as may be necessary to adequately protect and clear Patient’s account with Texas Regional Physicians – Urgent Care and Minor Emergency prior to and before any fees are paid to Attorney out of said statement. By this assignment, Patient gives this Lien on Patient’s claim to Texas Regional Physicians – Urgent Care and Minor Emergency against any and all proceeds of any settlement, judgement or verdict that may be paid to Attorney, or Patient or to another individual on Patient’s behalf, that results from the injuries and illnesses in connection thereto, for which Patient has been treated. If Patient assigns any or all of the Patient’s rights to his or her claim or a portion thereof, Patient agrees to notify Texas Regional Physicians – Urgent Care and Minor Emergency, in writing, at the below address within thirty (30) days from the date of assignment. If another attorney is substituted in this matter, the new attorney shall honor this Lien as inherent to Patient’s claim, and notice of, and substitution of, this Lien shall be both Patient and Attorney’s responsibility.

NOTICE

This Lien may be executed in one or more counterparts, ease of which shall be deemed to be an original but all of which together will constitute one and the same instrument. It is understood and agreed that a copy of this Lien shall have the same force and effect as the original. Texas Regional Physicians – Urgent Care and Minor Emergency is authorized, but not required, to file a copy of this Lien.

PAYMENT RESPONSIBILITY

Patient understands that Patient remains personally responsible to Texas Regional Physicians – Urgent Care and Minor Emergency for all medical bills submitted for service rendered to Patient and that this Lien is made solely for Texas Regional Physicians – Urgent Care and Minor Emergency protection and in consideration of awaiting payment. Patient further understands that such payment is not contingent on any claim, settlement, judgement or verdict by which Patient may eventually recover said fee. Patient shall notify Texas Regional Physicians – Urgent Care and Minor Emergency of any payment received by Patient for medical services from an insurance company or any other source. Payments will be forwarded to Texas Regional Physicians – Urgent Care and Minor Emergency as requested. Patient further understands and accepts financial responsibility for payment of all accounts with Texas Regional Physicians – Urgent Care and Minor Emergency. Patient understands that the legal settlement may pay all, part or none of Patient’s account(s) and that Patient is responsible for complete payment of all account(s). Patient understands that Patient is financially responsible for any amount unpaid by this assignment or proceeds and/or Lien, as may be authorized by applicable state law and practice. By signing this document, Patient fully understands all provisions set forth in this.

NOTICE OF PRIVACY PRACTICES - I have been provided the opportunity to read, review and gain access to the Texas Regional Physicians – Urgent Care and Minor Emergency, its assignees and third-party’s notice of privacy practices. I understand that I am entitled to a copy of these practices at my request.

NOTICE OF HIPAA - I furthermore acknowledge that I have the right to designate access to my Protected Health Information (PHI) to anyone of my choosing.

NOTICE OF PRIVACY PRACTICE

Keeping the medical and health information we have about you secure, is one of our most important responsibilities. We value yur trust and will handle your information with care. Our employees access information about you only when necessary, to provide treatment, verify eligibility, obtain authorization, process claims and otherwise meet your needs. We may also access information about you when considering a request from you or when exercising our rights under the law or any agreement with you.

We safeguard information during all business practices according to established security standards and procedures, and we continually assess new technology for protecting information. Our employees are trained to understand and comply with these information principles.

We limit who receives information and what type of information is shared.

Sharing information within the Practice. We share information within our company to deliver you the healthcare services and the related information and education programs specified in your plan. 

Sharing information with companies that work for us. To help us offer you our services, we may share information with companies that work for us, such as claim processing and mailing companies and companies that deliver health education and information directly to you. These companies act on our behalf and are obliged contractually to keep the information that we provide them confidential.

Other. Patient-specific personally identifiable data is released only when required to provide a service for you and only to those with a need to know, or with your consent. Data is released with the condition that the person receiving the data will not release it further, unless you give permission.

If we receive a subpoena or similar legal process demanding release of any information about you, we will attempt to notify you (unless we are prohibited from doing so). Except as required by law or as described above, we do not share information with other parties, including government agencies. The Practice does not share any customer information with third party marketers who offer their products and services to our patients.

You can count on us to keep you informed about how we protect your privacy and limit the sharing of information you provide to us --whether it's at our office, over the phone or through the Internet.

If you have questions regarding your privacy rights, please call the Complete Pain Solution Privacy Officer at 713-554-3207. If you believe your privacy rights have been violated, you may file a complaint by contacting Complete Pain Solution at 713-554-3207 or by email at ktran@memorialdiagnostic.com, or with the U.S. Department of Health and Human Services.

You will not be penalized for filing a complaint. The address for the U.S. Department of Health and Human Services is:

 

Office For Civil Rights

US Department of Health and Human Services

Atlanta Federal Center

Suite 3870

61 Forsyth St., SW

Atlanta, Georgia 30303-8909

(404) 562-7886 (phone)

(404) 562-7881 (fax)

(404) 331-2867 (TDD)

www.hhs.gov/ocr/hipaa

 

I understand I may revoke this authorization at any time by submitting a written request to Texas Regional Physicians – Urgent Care and Minor Emergency’s Privacy Officer, as per the office’s Notice of Privacy Practices.

I understand that by signing this authorization, this information will be used by Texas Regional Physicians – Urgent Care and Minor Emergency to make determinations for the release of my PHI. I also understand this authorization will remain in effect until I request an update and/or amendment.

I authorize Texas Regional Physicians – Urgent Care and Minor Emergency, its assignees and third-party collection agents to use the contact information I have provided to communicate with me and to place calls to my home/cell/employment phone numbers, leave voice or text messages and use pre-recorded/artificial messages and/or autodialing devices in connection with any communication to me.

I hereby authorize release of my films and/or medical records as needed for subsequent medical care. In the event of positive findings, I authorize my attending physician to release the results of my biopsy-surgery to my referring physician named above for their records.

If someone other than the patient is signing this authorization, please state relationship with patient and the reason patient is unable to sign.

CONSENT TO TREAT FOR WEIGHT LOSS SPECIFICALLY -

I authorize this establishment and all subsidiaries to assist me in my weight loss efforts. I understand there are potential risks to a weight loss program such as:

1. Allergic reactions to prescribed medications and supplements 
2. Side effects of medications 
3. Inconvenience of lifestyle changes 
4. Mild hair loss from rapid weight loss 
5. Risk of conditions such as gout and an inflamed gallbladder due to weight loss in
6. sensitive individuals 
7. Muscle loss that can occur with any weight loss program but can be minimized by consuming the proper diet with plenty of protein, as well as with exercise, and supplements such as collagen. 

Part of my treatment may involve the use of prescription medications, including but not limited to appetite suppressants. Some of these medications are controlled substances, some are FDA approved for weight management, and some may be used off label for weight management. If you are prescribed our semaglutide or tirzepatide sublingual products, it is feasible that some patients may require a higher dose of these medications.  We establish the initial dose by considering medical history, and the dose that works for most, but occasionally, it is necessary to raise the dose for optimal therapeutic outcomes. Users of these products may experience a non-responder rate of 10-15%, based on what was observed in trials of Ozempic, the commercially available medication, and isn’t limited to our custom formulations. I understand that some medications and supplements may cause some side effects in certain sensitive individuals, may interact with certain prescription medications or lab tests, or cause symptoms due to certain pre-existing disease conditions. I do not expect my medical provider to be able to anticipate and explain all risks and potential complications. I wish to rely on the judgment of the medical providers in recommending programs that they feel are in my best interest, based on the available knowledge. The Medical Providers of this establishment and all subsidiaries, use the manufacturer’s labeling as a source of information when prescribing medications, along with their own experience, the experience of colleagues, recent longer-term studies, and recommendations of university-based investigators. You must decide if you are willing to accept the risks of possible side effects (even if they may be serious), for the possible help the weight loss medications (used in a manner we may deem necessary) may give. Though these effects are unlikely, some may be serious & fatal if left uncontrolled. They include but are not limited to the following: 

1. Allergic reaction 
2. Rapid heart beat and irregular heart beat 
3. Headache 
4. Dry mouth 
5. Constipation 
6. Nausea, vomiting 
7. Diarrhea 
8. Abdominal pain 
9. Jitteriness 
10. Dizziness 
11. Insomnia 

I will have the opportunity to ask questions and discuss with the medical staff to my satisfaction, the following: 

1. My condition 
2. The nature, purpose, and potential benefit of the proposed medical weight loss program(s) 
3. The potential risks associated with the medical weight loss program(s) 
4. The probability of those risks occurring 
5. The likelihood of success 
6. The possible consequences if advice is not followed and/or no weight loss programs are undertaken 

 
I understand that at each of my appointments, my weight, blood pressure and pulse will be recorded. A photocopy of my driver’s license, state issued identification card or passport will be taken to be kept in my chart for physical identification and will also be kept confidential. 
 
I understand I may be required to undergo certain tests, if deemed medically necessary prior to starting a program. These tests may include EKG, blood chemistry panel, thyroid panel, CBC. 
 
I understand it is my responsibility to follow the instructions carefully and to report to establishment and all subsidiaries* any significant medical problems I think may be related to my weight control program, as soon as reasonably possible. 
 
I am aware there are certain risks involved with those who are overweight or obese. Among these risks are tendencies to have high blood pressure, diabetes, heart attacks, heart and/or vascular disease, premature death, gallbladder disease, osteoarthritis, endometrial cancer, hyperlipidemia to name a few. I understand these risks may be modest if I am only slightly overweight, but greater if I am 20% or more above my ideal body weight. I do understand the more overweight I am, the greater risk I have for the above tendencies. 
 
I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand my continuing to receive the medication will be dependent on my progress and efforts in the weight reduction and weight maintenance program. 
 
I understand that much of the success of the program will depend on my own personal efforts, and that there are no guarantees or assurances that the program will be successful. I also understand that I will need to make a lifelong commitment to informed and healthful eating habits in order to maintain my weight loss. I understand that if I do not feel the medication is working or I experience side effects, I will notify TRP of any adverse effects and discuss with my licensed medical provider. I understand that my provider may instruct me to discontinue the medication and/or may recommend a different type of medication or a different dose. I understand that I would be responsible for the cost of any additional medication. I understand the medication is ordered by TRP on my behalf from a third-party pharmacy and that the pharmacy is unable to accept returns or issue refunds of medication. 
 
I understand that there are other ways and programs that can assist me in my desire to decrease my body weight, and to maintain this weight loss. A balanced calorie counting program or an exchange eating program, without the use of prescription medications, may be successful, if followed. 
 
I have fully read and understand this consent form, and I realize that I should not sign this form if I have any questions concerning this program. I have been urged to take all the time that I need in reading and understanding this form, and in talking to establishment and all subsidiaries, or my own personal physician (if different) regarding risks, side effects, and benefits of the medications and programs. I understand and agree that medications prescribed and dispensed to me by Red Mountain Weight Loss or Nationwide Compounding RX and/or Strive Compounding Pharmacy are not eligible for return or refund. I understand and agree that all medication sales associated with my Red Mountain weight loss program(s) are final. 

TELEMEDICINE
 
I understand that at any time during the course of my 
treatment by TRP Weight Loss, I may choose to be seen via a 
“Telemedicine Appointment” which means that I will be evaluated and treated by a health care provider from a different location via electronic communication. 
 
I understand, that I will be seen by a licensed medical provider with TRP Weight loss, who  will be at a different location than I. 
 
I understand that I am responsible for being in a location and on a device that 
has a strong and reliable internet connection for the duration of my 
telemedicine appointment. 
 
I understand that I must have a reliable scale to use at home, or that I must 
come into a TRP office to be weighed prior to my appointment. 
 
Athena is a secure HIPAA Compliant program used as a platform for all of TRP Weight loss’s telemedicine appointments. I agree to give Athena access to my device camera and microphone for the duration of my telemedicine appointment so that the staff at TRP weight Loss may see and hear me clearly, and so that I may see and hear them clearly. 
 
My signature below indicates that I have been informed of the above and have been counseled regarding the side effects of medications. 
 
Please type full name here, and sign in the box below: