TXWOUNDX.COM-WOUND CARE

PATIENT INFORMATION
Patient’s Name*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
Date
Patient’s Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Contact#:*
Please enter a valid phone number.
Alternate#:
Please enter a valid phone number.
Work#:
Please enter a valid phone number.
Email:
example@example.com
Sex:

MaleFemale
Social Security# (optional):
Marital Status:

SingleMarriedDivorcedWidowed
Emergency Contact Information:
Contact Name:
Phone#:
Please enter a valid phone number.
Alternate#:
Please enter a valid phone number.
Relationship:
Physician:
Referring Physician:
Phone#:
Please enter a valid phone number.
Primary Insurance:
Insurance Provider:*
Policy Holder:*
Policy#:*
Group/Acct#:*
Employer Name:
Employer Contact#:
Please enter a valid phone number.
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance:
Insurance Provider:
Policy Holder:
Policy#:
Group/Acct#:
Employer Name:
Employer Contact#:
Please enter a valid phone number.
Employer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
*If Patient is a minor or Power of Attorney is involved in care:
Parent/Guardian Name:
Relationship:
Parent/Guardian Name:
Relationship:

CONSENT FOR TREATMENT
I hereby give my permission for Lammons Healthcare & Associates, PLLC and its associates or assistants to examine and render treatment as may be necessary in the diagnosis and/or treatment of my weight management and release related information to my physician and/or emergency medical personnel as required by law. Treatment may include examination, medication administration, and other various weight management related/reasonable therapies.
Signature:*

Clear
Date:*

MonthDayYear
Date
Printed Name:*

ASSIGNMENT OF BENEFITS/FINANCIAL POLICY
As insurance coverage decreases and the patient's financial responsibility increases, we understand the need for clear and concise communication of our financial policies. Unfortunately, most insurance no longer covers services fully and many insurance plans chosen by our patients may require significant out-of-pocket expenses to be paid by the patient. With continuous changes in coverage, it is important to verify your benefits and be aware of all restrictions, limitations, and expenses of your plan.

It is your responsibility to verify that all requirements of your insurance plan are met. We will assist you with precertification for procedures ordered by our office, but your responsibility is to verify whether your insurance plan covers any care rendered. We are not responsible for the expense of treatment, which is not paid by your insurance.

I hereby authorize my insurance company to pay directly to Lammons Healthcare & Associates, PLLC the benefits and amounts due and otherwise payable to me for medical supplies and services, as described on the customary charges for all supplies and services. I acknowledge and understand that I am responsible for all the charges for all services rendered to me or any member of my immediate family. If for any reason, any portion of my bill is not paid by my insurance company, I further agree to make arrangements for prompt and timely payment of the balance. I further acknowledge that I read and understand the financial policy. I accept responsibility for the payment of any balance owed on my account. I understand I am financially responsible for all charges whether paid by insurance.
Signature:*

Clear
Date:*

MonthDayYear
Date
Printed Name:*

MEDICARE (IF APPLICABLE)
I hereby authorize my insurance company to pay directly to Lammons Healthcare & Associates, PLLC the benefits and amounts due and otherwise payable to me for their services, but not to exceed the customary charges for those services. I understand that I am financially responsible for all remaining charges incurred whether or not covered by said insurance.
Signature:*

Clear
Date:*

MonthDayYear
Date
Printed Name:*

AUTHORIZATION AND CONSENT FOR USE OF RECORDING DEVICES FOR MEDICAL DOCUMENTATION
Lammons Healthcare & Associates, PLLC (including WoundX) is committed to enhancing the accuracy, efficiency, and quality of medical documentation. As part of this process, recording devices may be used to capture verbal dictation of SOAP (Subjective, Objective, Assessment, and Plan) notes, which are then transcribed and entered into the Electronic Medical Record (EMR). This method improves workflow efficiency, ensures accurate and timely documentation, and enhances overall patient care.

By signing below, you acknowledge and agree to the following:

1. Authorization for Recording: You authorize Lammons Healthcare & Associates, PLLC and its designated providers to use audio recording devices to document SOAP notes for medical purposes. These recordings are intended solely for clinical documentation and will not be shared, distributed, or used for any purpose beyond patient care and recordkeeping.

2. Confidentiality & HIPAA Compliance: Lammons Healthcare & Associates, PLLC adheres to all HIPAA regulations and confidentiality standards to protect patient information. Recordings will be securely stored and deleted upon successful transcription into the EMR.

3. Efficiency & Accuracy: The use of recording technology streamlines documentation, reducing administrative burdens and ensuring the correct and complete logging of medical notes, leading to improved patient outcomes.

4. Limited Use & Access: Access to recorded dictations will be restricted to authorized medical personnel responsible for transcription and documentation. No recordings will be used for training, research, or any other non-clinical purpose without prior written consent.

5. Right to Revoke: You have the right to withdraw this authorization at any time by providing written notice to Lammons Healthcare & Associates, PLLC. However, withdrawal will not apply to recordings already transcribed and incorporated into the medical record.

6. Acknowledgment of Consent: You understand that this authorization is voluntary and that declining or revoking consent may require alternative documentation methods.

By signing below, you acknowledge that you have read and understand this authorization and consent to the use of recording devices for SOAP note documentation.
Signature:*

Clear
Date:*

MonthDayYear
Date
Printed Name:*

PHOTO, VIDEO, AND AUDIT CONSENT
I hereby consent to allow Lammons Healthcare & Associates, PLLC., its agents, representatives, employees, successors, or assign to photograph, and/or videotape. I further grant to Lammons Healthcare & Associates, PLLC the right and permission to copyright, reproduce, broadcast, telecast, and/or publish the photograph(s), film, videotape, recordings, endorsement, or copy in which I may include in whole or part or composite form for utilization in diagnostics, documentation, treatment, and/or teaching or demonstration purposes, or art purposes, trade, website use, advertising, and all advertising media, or for any lawful reproduction purpose.

I understand that these images will be stored in a secure manner to protect them from unintended use by unauthorized parties. I understand and agree that these images/recordings may include inferring information regarding medical conditions and/or treatment at the Lammons Healthcare & Associates, PLLC locations and affiliated entities.

I understand and agree that I have the right to rescind this agreement and Lammons Healthcare & Associates, PLLC., will not make any additional media placement of my images or recordings. I also understand that Lammons Healthcare & Associates, PLLC., will not withdraw any media where my images or recordings have already been placed. To rescind approval, I must submit a request in writing to Lammons Healthcare & Associates, PLLC.
Signature:*

Clear
Date:*

MonthDayYear
Date
Printed Name:*

AUTHORIZATION TO RELEASE INFORMATION
I, blanks* hereby authorize Lammons Healthcare & Associates, PLLC., to release any information regarding medical treatment for the purpose of validating and determining benefits payable in connection with claims. I may revoke consent for the above item at any time in writing. I also understand that there is a $25 non-refundable fee for any requested medical records or the completion of any forms, including FMLA, and others.
Signature of Patient or Guardian:*

Clear
Date: *

MonthDayYear
Date
Printed Name:*

PRIVATE INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS AND PRIVACY PRACTICES
I, blanks the undersigned, authorize payment of medical benefits to Lammons Healthcare & Associates, PLLC. for any services furnished to me by the physician. I understand I am financially responsible for any amount not covered by my insurance policy. I also authorize Lammons Healthcare & Associates, PLLC. to release to my insurance company, referring physician, insurance companies and other consultants on my case information concerning health care advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
By signing this document, I acknowledge that I have been given the opportunity to read the Notice of Privacy Practices of Lammons Healthcare & Associates, PLLC.
NOTICE OF PRIVACY PRACTICES
Protected Health Information may be disclosed to insurance companies, managed care organizations, or referring physicians in the course of treatment, payment, or healthcare operations. When information is disclosed to another entity, it may be subject to redisclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule. You have the right to refuse or restrict disclosure of your information.
Signature:*

Clear
Date:*

MonthDayYear
Date
Printed Name:*
Should be Empty:

	Yes	No	Family
Diabetes
Chest Pain
High Blood Pressure
Heart Disease
Heart Attack
Stroke/CV A
Heart Palpitations
Pacemaker
Headaches
Kidney Problems
Seizures
Cancer
Osteoporosis
Bowel/Bladder Abnormalities
Urine Leakage
Blood Virus (HIV, Aids)
Asthma or Breathing Difficulties
Liver/Gallbladder Problems
Eye Disorders
COPD/Lung Issues
Blood Clotting
Lymphedema
Smoking/ Tobacco Use
Allergies to Medication
Environment Allergies
Other Allergies
Are you on Blood Thinners?
Hernia
Are you pregnant?
Metal Implants
Dizziness/Fainting
Bone Fracture
Skin Abnormalities
Sinus Problems
Sexual Dysfunction
Nausea/Vomiting
Ringing in your ears
Rheumatoid Arthritis
Kidney Stones
Recent Cardiology Workup
Other Implanted Devices
Anxiety or Depression
Radiation or Chemotherapy
Thyroid cancer
Thyroid problems
Pancreatic Cancer
Pancreatic Problems

PATIENT INFORMATION

Emergency Contact Information:

Physician:

Primary Insurance:

Secondary Insurance:

*If Patient is a minor or Power of Attorney is involved in care:

MEDICAL HISTORY

PHARMACY (list pharmacy most frequently used for prescriptions)

TOBACCO HISTORY

ALCOHOL AND DRUG HISTORY

CONSENT FOR TREATMENT

ASSIGNMENT OF BENEFITS/FINANCIAL POLICY

MEDICARE (IF APPLICABLE)

AUTHORIZATION AND CONSENT FOR USE OF RECORDING DEVICES FOR MEDICAL DOCUMENTATION

PHOTO, VIDEO, AND AUDIT CONSENT

AUTHORIZATION TO RELEASE INFORMATION

PRIVATE INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS AND PRIVACY PRACTICES

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

NOTICE OF PRIVACY PRACTICES