BOSS - New Patient Form

INFORMED FINANCIAL CONSENT/BILLING POLICY FOR SURGERY
FEES FOR PROCEDURES

If there is a need for surgery after your consultation, as a service to our patients, we provide an estimate of the likely medical costs you will be required to pay for your in-hospital or day surgery elective procedure.

Surgery quotes are valid for 6 months from the date of quotation. If your surgery is scheduled after this date, you will need to contact our rooms for an updated quotation closer to your surgery date.

Have Private Health? Are you covered?

The Australian Medical Association (AMA) sets a fee guide based on each individual operation. The Australian Government (Medicare) contribute a percentage to these fees known as the Medicare Rebate. Most health funds recognise the need for specialists to charge for their services. However, Health Funds are not always prepared to cover the full remaining difference between the surgeon's fees and the Medicare Rebate; the difference creates a 'gap'. The gap is an 'out-of-pocket' expense and will vary between $400 - $3000 depending on the procedure. All surgery amounts must be paid before surgery. After surgery, we will bill your account directly to Medicare and your insurer. Their contribution to your surgery will be refunded directly to you; this usually takes 14-21 days. Occasionally, the surgery performed will vary based on decisions made in the operating theatre once the doctor has a clearer view of your injury/condition. Your upfront costs will not increase or decrease to reflect this.

If you have any queries, discuss these costs with your doctor’s staff before your procedure to ensure you understand what costs you may be liable to pay yourself. You will be liable for any costs not covered by Medicare or your health fund.

Please note that this is an estimate only of the fees charged by this practice.

No Private Health? Are you covered?

The Australian Government (Medicare) still provide a rebate towards your operation; however, you will have an out-of-pocket expense. You will also need to cover hospital fees and any implants, prosthetics, or equipment used in theatre; this can range from $5000 to $30,000. Therefore, it is important we provide a full quote from the Private Hospital and the surgeon before you decide to go ahead.

OTHER FEES

Costs provided in our surgery quote cover the surgeon's fees only. Unless otherwise stated, it DOES NOT cover services provided by other doctors, such as anaesthetists, radiologists, nuclear physicians, out-patient physiotherapy or pathologists, or other costs associated with your stay in the hospital or day surgery unit, such as accommodation, pharmacy or in-hospital physiotherapy. If you require more information on the fees from other medical providers, your surgery paperwork will provide the contact numbers you can phone for an estimate.

PATIENT REGISTRATION FORM
WHICH DOCTOR IS YOUR CONSULTATION WITH:
Title:
Patient Surname:
First name: (as appears on Medicare card)
Preferred Name:
Patient's Street Address:

Street Address

Street Address Line 2

SuburbState / Province

Post Code
Patient's Mailing Address (if different from above):

Street Address

Street Address Line 2

SuburbState / Province

Post Code
Date of Birth:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Occupation:
Contact Phone Numbers:
Home:
Work:
Mobile:
Please include your email address should you wish to receive correspondence electronically.
Contact email address:
MEDICARE DETAILS – please complete carefully to ensure medicare reimbursement
I authorise you to contact Medicare on my behalf
Authorising Initials
I consent to Telehealth calls and billing on my behalf to Medicare as required
Initials
Name EXACTLY as it appears on your Medicare Card:
Medicare No.
*Ref:
Expiry Date:
* Note: Ref (reference number) is the small number in front of your name on the Medicare card.
DVA Number:
Expiry Date:
Type a question
What is covered:
Health Care Card/Pension Number:
Expiry Date:
*****RADIOLOGY - important please read: *****

If you do not have hard copies of your films to bring to your appointment, our practice may be able to view your investigations online, depending on where the radiology was originally performed. Please complete the below regarding your RELEVANT (to this appointment) radiology
Type a question

OTHER:

CONSENT FOR RELEASE & REQUEST OF INFORMATION
The Privacy Act requires us to obtain your permission to collect information about you. Below is a full disclosure of the personal information we collect.

Why we collect:

The primary reason is to provide you with quality health care and to properly assess and diagnose you.

How we collect:

We will take your personal details.

We may require you to complete forms about your condition.

Any past or future history from your external health care providers. Any relevant tests, including but not limited to pathology and radiology

How we use this information:

1. Communication

We use your health record to communicate with others involved in your care.

This includes your referring doctor who will receive a letter outlining the outcome of your consultation. It may also include specialists and therapists involved in your care.

2. Administrative purposes.

This includes maintenance of records and billing. If you have outstanding accounts, this information may also be forwarded to a collection agency.

3. Research and education.

Your doctor is involved in teaching, research and quality assurance. He/she may take photographs of your X-rays or operation and use them for teaching. Your name would NOT be disclosed. He/she collects information about the number, type and outcome of all operations done and may use this for research or quality assurance. Again, you would remain ANONYMOUS.

Disclosure of information

If you are attending the clinic as a private patient, we provide information about your treatment to those directly involved in your medical management and care, i.e., your referring general practitioner or specialist. If your appointment is covered financially by a third party for workers' compensation, insurance, or medicolegal purposes, please note that we may release any report requests or billing information to the third party upon request; the practice liaises directly with the third party regarding this. You may wish to list a next of kin. By listing a next of kin, you consent to information regarding your appointments and care being discussed directly with those listed on your file.

Consent to contact third party organisations on your behalf

At times, we may be required to contact third-party organisations on your behalf; these may include, but are not limited to, WorkCover, DVA, Medicare Australia, health funds, etc. By signing this consent form, you give Brisbane Orthopaedic Specialist Services permission to contact these organisations regarding your treatment if required.

Accuracy and access

You can discuss your medical record with your treating doctor at any appointment. If at any time you feel a record on your file is not accurate, please advise the specialist for an amendment.

How your information is protected

Your medical record is held on a private, password-protected server. The Privacy Act governs it.

Changes to your information

Any changes to the information housed on your medical record will always be made as an amendment to the original file. The original document will remain.

You are not required to provide this information or give permission for it to be used as described above. However, failing to do so may compromise the treatment we can provide.

I have read and understood the above. I agree to provide the necessary information and for it to be used for the purposes outlined above.
Authorising signature (please write your full name below; this will be accepted as your electronic signature). If you are signing as a parent or guardian, please list your full name below.
Signature
Date

DayMonthYear
Should be Empty: