Patient Registration Form and Medical Lien Agreement (PI Lien)

PATIENT REGISTRATION FORM (PI Lien)
Date

MonthDayYear
Date
Demographic Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Marital Status*
Social Security
Address*

Home Address

Street Address Line 2

CityState

Zip Code
Phone number*
Can we text you?*
Email
example@example.com
Occupation
Employer
Attorney Information
Name of Law Office
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Address

Address

Street Address Line 2

CityState

Zip Code
Paralegal Case Manager
Direct Phone Number
Preferred Pharmacy
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Emergency Contact
Name
Relationship to Patient
Phone number
If under 18 years name of parent or Guardian
The above information is true to the best of my knowledge. / authorize Dee Sports Orthopedics to release any information required to process my claims.
Patient signature Responsible Person*

Clear
Date*

MonthDayYear
Date
Initial Here*

ACKNOWLEDGEMENT OF OFFICE POLICIES
The following are Dee Sports Orthopedics' policies governing appointment scheduling, payment terms, and information release. Please read carefully and be sure to ask questions you might have before signing the document.

Appointment Scheduling: We require a 24-hour cancellation notice for all appointments. If you miss three (3) or more appointments without 24- hour notice, you may be dismissed from care and your file may be closed.

Consent for treatment: I, the undersigned, give Dee Sports Orthopedics permission to evaluate and treat my injury. I further understand that during recommended treatment, condition may worsen on rare occasions. I further understand that no guarantee or promise has been made to me concerning the results of treatment.

Assignment of Payment: I hereby authorize my attorney to pay directly to Derek T. Dee, MD, any monies due on my account for professional services rendered.

Acknowledgement and Understanding: It is further understood that I, the undersigned, agree to pay the full charges should my condition be such that is not covered by my policy, or if, for any reason, my attorney refused to pay my

Authorization to Release Information: I have read and fully understand Dee Sports Orthopedics' Notice of Privacy Practices. I understand that Dee Sports Orthopedics may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payments, understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administration operation if I notify the practice. | also understand Dee Sports Orthopedics will consider requests for restriction on a case-by-case basis but does not have to agree to requests for restrictions. Dee Sports Orthopedics reserves the right to change the terms of the Notice of Privacy Practices, and to make changes regarding all protected health information by this practice. If changes to the policy occur, Dee Sports Orthopedics will provide a revised Notice of Privacy Practices upon request. I understand that I may revoke this consent in writing at any time.

Patient Requests for Records: I instruct the release of all medical, hospital, or surgical records pertinent to my case, including, but not limited to, special tests, x-rays, or lab results to this office.

I do hereby consent and acknowledge my agreement to the terms set forth in the Notice of Privacy Practices and any subsequent changes in the office policy. I understand that this consent shall remain in force from this time forward.
Patient signature/ Responsible Person*

Clear
Date*

MonthDayYear
Date
Initial Here*

INJECTION CONSENT FORM
The purpose of this document is to provide written information regarding the risks, benefits, and alternatives of joint injections. This is supplementary to the discussion you will have with Dr. Dee. It is important that you fully understand this information.

The Procedure: After the skin surface is thoroughly cleaned, the joint, or soft tissue, is entered with a needle attached to the syringe. At this point, either joint fluid can be obtained and sent for appropriate laboratory testing or medications/Platelet Rich Plasma/Regenerative Therapy can be injected into the joint space.

Benefits:You might receive the benefit of relief from pain and swelling with this procedure, but this cannot be guaranteed. Only you can decide if the benefits are worth the risk.

Risks:Before undergoing this procedure, understanding the associate risks is essential. No procedure is risk-free. The following risks are well recognized:

Allergic reaction to the medications injected into joints, to tape, or chemicals that are used to clean the skin.There may be an infection, although extremely rare. You may develop "post-injection flare" which is joint swelling and pain for several hours after any injection.Local fat atrophy (thinning of the skin) at the injection site.
Rupture of a tendon located in the path of the injection if inadvertently injected.

Alternatives:Oral anti-inflammatory drugs such as ibuprofen or naproxen
Physical therapy

I consent to being informed for any future injection procedure(s), including risks, benefits, and alternative detailed above.
Patient signature Responsible Person*

Clear
Date*

MonthDayYear
Date
Initial Here*

X-RAY & FLUOROSCOPY CONSENT
Dr. Dee may request an x-ray to obtain additional information. X-rays produce images of the internal body parts being examined. X-rays are painless; however, radiation is emitted.

Patient Consent to X-Ray:

I authorize Dr. Dee, MD to perform a diagnostic x-ray examination on myself and to administer recommended treatments that are deemed medically necessary.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Females: Regarding the possibility of pregnancy

If you are pregnant or think you may be pregnant, please inform the office immediately.

This is to certify that, to the best of my knowledge, I am not pregnant, and Dr. Dee has my permission to perform a diagnostic x-ray examination.
Patient Signature

Clear
Date

MonthDayYear
Date
If Patient is a Minor

I am the parent or legal representative of the patient. I authorize the performance of diagnostic x-rays of this minor of diagnostic x-rays of this minor.
Patient signature/ Responsible Person

Clear
Date

MonthDayYear
Date
Initial Here

GENERAL MEDICAL HISTORY
Weight (in lbs.)*
Height (in feet and inches)*
Surgical History (Type of surgery and doctor, Date, Physician). Please put N/A if no past surgical history.*
Prior Injuries (Worker's Compensation, Motor Vehicle Accidents, Slip/Fall). Kindly indicate Body part, description, and date. Please put N/A if none.
Prior treatments/ injections. Kindly indicate Body part, description, and date. Please put N/A if none.
Current Medications: (Name, Dose/Strength, Directions). Please put N/A if none.*
Allergies: (Allergen, Reaction). Please put N/A if none.*
Social Background
Do you smoke?*
If yes, how many packs per day?
How many years have you been smoking?
Do you drink alcohol?*

YesNoOccasionallyDaily
Do you live with some who can take care of you at home?
If yes, who?
Initial Here

Medical-Legal Lien Agreement
Attorney*
Telephone Number
Please enter a valid phone number.
Facsimile
Please enter a valid phone number.
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Date of Injury*

MonthDayYear
Date
I do hereby authorize Derek Dee, M.D. to furnish you, my attorney, with prepaid copies of any and all medical records, chart notes, and reports relevant to the injury or accident for which you are representing me. I further authorize and direct my attorney to pay directly to Derek Dee, M.D., any and all sums due for medical treatment and services rendered to me, any medical supplies, reports, or follow-up services provided, and any legal-medical work, including but not limited to impairment ratings conferences with attorneys, and deposition-related services.

I hereby grant Derek Dee, M.D. an irrevocable lien on my claim and authorize him to receive full payment for all outstanding balances from any and all proceeds of any settlement, verdict, judgment, or award, whether paid to me, my attorney, or on my behalf. I instruct my attorney to withhold such sums as are necessary to satisfy this lien prior to disbursing any other funds.

In the interest of fairness to my treating physician, I authorize and instruct my attorney to provide Dr. Dee, or his authorized representative, upon request, with the total gross settlement amount, a full breakdown of disbursements including legal fees, costs, and medical liens, as well as the identities and lien amounts of all other providers or lienholders involved in my case. If multiple medical providers are asserting liens or balances, I instruct my attorney to ensure that Dr. Dee is paid at least his fair and proportionate (pro-rata) share of the total amount allocated to providers, unless a higher amount is agreed upon. I understand this ensures fair distribution among those who rendered care.

I fully understand and agree that I remain personally responsible for all medical charges incurred at Derek Dee, M.D.’s practice. This agreement is made in consideration of services rendered and as additional assurance of payment. I further acknowledge that payment to Dr. Dee is not contingent upon the outcome of my case or on the decisions of any third-party insurer, with the exception of an accepted workers’ compensation case. If there is no settlement or judgment, or insufficient funds, I remain financially responsible for the full amount owed. By signing below, I knowingly waive any right to challenge the enforceability of this lien. I confirm that I have reviewed this agreement with my attorney and understand its contents. This agreement is governed by the laws of the State of California. Pursuant to California Civil Code 1785.27, a holder of this medical debt contract is prohibited from furnishing any information regarding this debt to a consumer credit reporting agency. Any person who knowingly violates this law by reporting such debt to a consumer credit reporting agency shall render the debt void and unenforceable.
Patient's Signature*

Clear
Date signed*

MonthDayYear
Date
Attorney Acknowledgement

As the attorney for the above-named patient, I agree to honor this lien and its terms. I will withhold and promptly remit payment to Derek Dee, M.D., upon receipt of any settlement, verdict, or award. I will provide requested settlement and lienholder information upon request and ensure fair pro-rata distribution of provider payments if applicable. I understand that this lien is binding, and payment must be made without demand immediately upon disbursement of funds.
Attorney's Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

PATIENT REGISTRATION FORM (PI Lien)

Demographic Information

Attorney Information

Preferred Pharmacy

Emergency Contact

ACKNOWLEDGEMENT OF OFFICE POLICIES

INJECTION CONSENT FORM

X-RAY & FLUOROSCOPY CONSENT

AUTOMOBILE

Please check all that apply:

GENERAL MEDICAL HISTORY

Social Background

Medical-Legal Lien Agreement