Welcome to the Paley Institute
While completing this packet, please do not
hesitate to ask us any questions you may have.
Thank you!
Tenet Physician Services, LLC
Paley Advanced Limb Lengthening Institute
901 45th Street, Kimmel Building
West Palm Beach, FL 33407
P: 561.844.5255 F: 561.844.5245
PATIENT REGISTRATION FORM
Local Address (if different from above)_________________________________________________________________
)__________________________________ Home (
Daytime / Work No. (
Cell No. (
)__________________________
Local No. (
)_________________________
) _______________________________
Date of Birth ___________________________ Age _____________________ Sex: Female / Male
Marital Status (Circle One):
Single
Married
Divorced
Widowed
How would you like to be addressed?_________________________________________________________________
Email Address ____________________________________________________________________________ _____
If patient is a minor, Father’s Name ________________________ Mother’s Name ______________________________
Patient's Employer
Occupation ______________________________
Address ____________________________ City ______________________ State _________ Zip Code __________
Emergency Contact Person _______________________________________________________________________
Relationship ____________ Home No. (
Is your visit due to:
) __________________ Work No. (
)________________
Auto Accident _________ If yes, date of accident __________________________________
Worker’s Comp. __________ If yes, date of accident __________________________________
Whom may we thank for referring you to our office?
If referred by a physician: Name _____________ Office No. (
) _____________Fax No. (
)___________
Address _______________________ City ____________________ State _____________ Zip Code _____________
Preferred Pharmacy's Name_____________________________
City
State
Address __________________________________
Phone No.__________________________________
Second Pharmacy's Name________________________________ Address ___________________________________
City
State
Phone No. _______________________________________________
Census Data:
Religion ___________________________________________ Ethnicity _________________________________
Circle One:
Hispanic
Non-Hispanic
Please choose from the following list for your Race:
Alaskan Native
Asian
Black/African American
Hawaiian
Hispanic
Indian
Multi-racial
Native American
Other Race
Pacific Islander
Unknown
Not Reported
White
Please choose from the following list for your Preferred Language:
Albanian
Arabic
Armenian
Azerbaijani
Bosnian
· Bulgarian
Cambodian
Chinese
Creole
Czech
Danish
2
Dutch
English
Estonian
Farsi
Filipino
Finnish
French
German
Greek
Hebrew
Hmong
Hungarian
Indonesian
Italian
Japanese
Korean
Laotian
Lebanese
Lithuanian
Malayan
Mandarin
Norwegian
Other
Pakistan
Polish
Portuguese
Romanian
Russian
Samoan
Serbo-Croatian
Sign Language
Slovak
Spanish
Sudanese
Swahili
Swedish
Tagalog
Taiwanese
Thai
Turkish
Ukrainian
Vietnamese
Yiddish
INSURANCE
Are you personally responsible for the payment of your fees?
Yes
No
If no, who is?
Name _______________________________________ Relationship _____________________________ DOB ________________
Address _____________________________________ City ________________________ St ________ Zip Code _________________
Name of Primary Insurance Company __________________________________________________________
Policy #
Group # _______________________________________
Insured’s Name ____________________________________________ Relationship ______________________________________
Date of Birth ____________________________________________
Name of Secondary Insurance Company _______________________________________________________________________
Policy # ____________________________________________ Group # _____________________________________
Insured’s Name _____________________________________ Relationship _________________________________
Date of Birth ______________________________________
PLEASE READ AND SIGN THE FOLLOWING:
1. Payment for services is expected at time of service.
2. If insurance is filed, I authorize benefits to be paid directly to Tenet Florida Physician Services, LLC.
3. I am responsible for the balance on my account, regardless of insurance coverage. My failure to pay all outstanding
balances on my account may result in collection procedure.
4. I authorize the Paley Advanced Limb Lengthening Institute to release any information requested with regard to the
processing of my claims.
5. Failure to give 24 hour notice prior to canceling appointments may result in a cancellation fee charge to my account
not payable by health insurance.
How long will you be staying?
Patient's /Parent 's
Signature ______________________________________________________________ Date ________________________
3
Tenet Florida Physician Services
Paley Advanced Limb Lengthening Institute
Financial Policy
We appreciate the confidence that you have expressed in selecting Dror Paley M.D., F.R.C.S.C., or Craig
Robbins, M.D., for your healthcare needs and we look forward to working with you. If you have any
questions about our services, fees, or other aspects of your care, please feel free to discuss your
concerns with us.
A payment for your office visit is required at the time of service for:
•
•
•
•
Patients without insurance.
Patients with private insurance.
Patients who are not covered by one of our contracted insurance plans.
Patients who do not provide us with contracted insurance information. (We must have a copy of
your current insurance card on file.)
ALL MONIES OWED BY THE PATIENT: CO-PAYMENTS, DEDUCTIBLES, AND NONCOVERED SERVICES ARE PAYABLE AT THE TIME OF SERVICE.
For any service that is rendered by this office that is not a covered benefit of your insurance policy, it is
your financial responsibility.
Our staff will assist you in dealing with your insurance company, but it is your responsibility to know and
understand your own insurance policy. It is our sincere hope that this policy will be helpful and reduce any
confusion or misunderstanding at a later date.
Patient Name:
Patient’s / Parent’s Signature:
Date:
Tenet Florida Physician Services
Paley Advanced Limb Lengthening Institute
AUTHORIZATION TO RELEASE MEDICAL RECORDS
Patient:
_______________________________________
Name of Patient/Previous Names
________________________________________
Birth Date
_______________________________________
Street Address
________________________________________
City, State, Zip
AUTHORIZE MY CURRENT PHYSICIAN:
TO RELEASE PROTECTED HEALTH
INFORMATION TO:
________________________________________
Physician Name/Self
________________________________________
Street Address
________________________________________
City, State, Zip
Dror Paley, MD, FRCSC
Craig Robbins, MD
901 45th Street, Kimmel Building
West Palm Beach, FL 33407
INFORMATION TO BE RELEASED:
I hereby authorize you to release all of my medical records for any treatment and laboratory/diagnostic
tests performed except for information pertaining to:
Sexually transmitted disease
____ Treatment of alcohol or substance abuse
Records from other facilities / providers
Testing or treatment of HIVIAIDS
Communication between patient and
psychotherapist for mental health treatment
For the Following Date(s):
_
PURPOSES FOR NEED OF DISCLOSURE: (check one)
_____ Further Medical Care
_____ Other (Specify):
Insurance/Eligibility
_
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:
I understand I must be provided with a signed copy of this authorization. I understand written notification
is necessary to cancel this authorization and I may obtain information on how to withdraw my
authorization by contacting the office of the above noted provider. I understand that Tenet Florida
Physician Services will not be able to release my records to someone else without a signed authorization.
If I decide not to sign this form, Tenet Florida Physicians Services will not refuse to continue treatment.
By signing this authorization, I do expressly and voluntarily consent to the disclosure of the information
checked above to the person/doctor/agency named. I understand that if the perso n(s) and/or
organization(s) listed above are not mandated by federal privacy standards, the health information
disclosed as a result of this authorization may be re-disclosed without obtaining my authorization. I
understand that I may be charged a fee for copying these medical records.
Signature Patient / Legal Rep. _____________________________________ Date _______________
(If signed by other than patient, state relationship and authority to do so)
Expiration Date: This authorization is good until the following date(s) __________________________
or for six months from the date signed.
Distribution of Copies: Original to provider; copy to patient; copy to accompany released records
Tenet Florida Physician Services
Paley Advanced Limb Lengthening Institute
Authorization for Use and Disclosure of Individually Identifiable Health information and Confidential Information
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I
understand that the information I authorize to a person or entity to receive may be re-disclosed and no longer protected
by federal privacy regulations.
1.
Persons/organizations authorized to use or disclose the information: Tenet Florida Physician Services, LLC and
its employees or contractors.
2.
I acknowledge and agree that the practice may disclose my protected health information and information
contained in my medical record to the following (check allowances)  Spouse  Adult children  All family members
 Legal representatives  Guardians  Health care surrogates  Other __________________________  All listed
3.
Specific information that may be used/disclosed: information relating to treatment, payment, and health care
operations.
4.
The information will be used/disclosed for: treatment, payment, and health care operations.
5.
I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to
sign or my revocation of this authorization will not affect my ability to obtain treatment; receive payment; or
eligibility for benefits unless allowed by law.
6.
I understand that I may inspect or copy the information used or disclosed.
7.
I understand that I may revoke this authorization at any time by notifying the person/organization providing the
information in writing, except to the extent that (a) action has been taken in reliance on this authorization; or (b)
if this authorization is obtained as a condition for obtaining insurance coverage, other law provides the insurer
with the right to contest a claim under the policy.
8.
I have read and agree to the information regarding "How We May Use and Disclose Medical Information about
You." Our notice of "Privacy Practices" (posted in reception) provides information about how we may use and
disclose health information about you. You have the right to review our notice before signing this form. The
practice reserves the right to change the terms of its Notice of Privacy Practices at any time. If so, the patient
may obtain a copy of this revised Notice. You have the right to request that we restrict how protected health
information about you is used or disclosed for treatment, payment, or health care operations. We are not
required to agree to this restriction, but if we do, we are bound by our agreement.
9.
By signing this form, you consent to our use and disclosure of protected health information about you for
treatment, payment, and health care operations as described in our notice. You have the right to revoke this
consent, in writing, except where we have already made disclosures in reliance on your prior consent.
10. Patient agrees and consents to the practice releasing information to the patient in the following alternative
manners:
 Via regular mail with envelope being marked personal and confidential, and addressed to the patient.
 Via telephone, if the patient contacts the practice and provides the appropriate information (name, SSN, birth
date).
The practice may refuse to treat the patient if he/she (or an authorized representative) does not sign this consent form. If the
patient (or an authorized representative) signs this consent form, and then revokes it, the practice has the right to refuse to
provide further treatment to the patient as of the time of revocation (except as the practice is required by law to treat individuals).
I have read and understand the information in this consent. I have received a copy of this consent and I am the
patient, or am authorized to act on behalf of the patient to sign this document verifying consent of the above stated
terms.
Signature of patient or patient's representative
Date
Tenet Florida Physician Services
Paley Advanced Limb Lengthening Institute
A notice of Privacy Practices (NPP) is provided to all patients. This Notice of Privacy Practices identifies: 1. How
medical information about you may be used or disclosed; 2. Your rights to access your medical information, amend your
medical information, request an accounting of disclosures of your medical information, and request additional restrictions
on our uses and disclosures of that information; 3. Your rights to complain if you believe your privacy rights have been
violated; and 4. Our responsibilities for maintaining the privacy of your medical information.
The undersigned certifies that he/she has read the foregoing, received a copy of the Notice of Privacy Practices and is the
patient or the patient's personal representative.
Name of Patient
Signature of Patient
Date Signed
Name of Patient's Personal Representative
Signature of Patient's Personal Representative
Date Signed
FOR INTERNAL USE ONLY
Name of Employee
Signature of Employee
If applicable, reason patient's written acknowledgement could not be obtained:
 Patient was unable to sign.
 Patient refused to sign.
 Other:
Paley Advanced Limb Lengthening Institute
Patient Disclosure: Consulting Agreement with Orthopaedic Companies
Dear Patients:
The Paley Institute is committed to providing the highest level of transparency to our patients. In
order to fulfill our commitment we want to provide you with information regarding Dr. Paley's
consulting agreements with orthopaedic companies.
Dr. Paley is a member of the American Academy of Orthopaedic Surgeons (AAOS), which holds its
members to the highest ethical standards to ensure that even the appearance of a conflict of
interest does not jeopardize the trust of the patient.
AAOS has adopted Standards of Professionalism that require Orthopaedic surgeon members to
identify and disclose potential conflicts of interest to their patients, the public, and colleagues.
These standards also clearly articulate how and under what circumstances AAOS members may
work with and be compensated by industry, as well as the penalties for failure to comply.
Dr. Paley has been active in his career with research and development of new implants and
improved surgical instruments and techniques. As part of this work, he has worked under contract
with orthopaedic companies, providing consulting services on new products and input on research
and development. In addition, Dr. Paley has given instructional lectures on implants and surgical
techniques for other doctors and medical personnel. In return for his time and expertise, Dr.
Paley has been paid a consulting fee.
Currently, Dr. Paley is a paid consultant to Smith and Nephew, 3D Medical, Pega Medical,
Ellipse, and Springer Publishing. Our office uses products from Smith and Nephew, 3D Medical,
Pega Medical, Ellipse, and Springer Publishing in the care of patients, but we also use similar
products from other implant manufacturers. We want to assure you that the selection of which
products to use in your care—and in the care of all out patients—is based only on what is best for
the patient, not on which company makes the product.
You can learn more about these Standards of Professionalism at the AAOS website:
http://www.aaos.org/industryrelationships
It is important to our office that you are aware of these relationships with implant
manufacturers, that our office puts the interests of patients first, and that we are
available to answer any questions that you may have.
Patient Signature
Date
Tenet Florida Physician Services
CONSENT FOR TREATMENT AND FINANCIAL AGREEMENT
CONSENT FOR MEDICAL SERVICES & TREATMENT
I consent to treatment, diagnostic and/or therapeutic services as
ordered and/or provided by Dr. ______________
as a physician of
Tenet Florida Physician and his/her designee(s).
FINANCIAL AGREEMENT
The undersigned individually obligates him/herself and guarantees
prompt payment of all charges for services rendered to the patient
when not covered by insurance carriers or others. Payment of any
unpaid balance is due within 30 days of final billing. If payment is not
received within 30 days of the date of final billing, finance charges
may begin to accrue at the maximum rate allowable by law. In
addition such balance may be turned over for collection activity, at
which time the undersigned shall be liable for attorney’s fees and/or
collection agency fees and expenses. The undersigned understand that
Tenet Florida Physicians has the right to examine credit bureau files
for financial information regarding collection of unpaid debt.
ASSIGNMENT OF BENEFITS
In the event that I am entitled to physician benefits of any and all
types, I assign such benefits to Tenet Florida Physicians for services
rendered to me. I authorize payment directly to Tenet Florida
Physicians of all such insurance benefits payable to me. Such
insurance includes, but is not limited to, private commercial
insurance, auto/liability insurance, or any governmental program such
as Medicare, Medicaid, or Worker's Compensation and authorize
Tenet Florida Physicians to release medical information to such
insurance providers as necessary to satisfy conditions for payment of
the assigned benefits. I certify that the information given regarding
my insurance is accurate and current.
RELEASE OF INFORMATION
I also authorize Tenet Florida Physicians to release all or part of my
medical record information when required or permitted by law or
government regulation, including any physician(s) or healthcare
provider responsible for continuing my care.
INSURANCE PRECERTIFICA TION
I understand that, before service is rendered, I personally am
responsible for any required notification to my insurance company to
FORM ·02/99
obtain authorization for treatment. If this is not done, insurance
benefits may be reduced and I am responsible for all charges not
covered by my insurance.
LIFETIME MEDICARE B & MEDIGAP SIGNATURE
AUTHORIZATION
I request that payment of authorized Medicare benefits be made either
to me or on my behalf for any services furnished to me by or in the
Tenet Florida Physicians, including physician services. I authorize any
holder of medical or other information about me to release to the
Centers of Medicare & Medicaid Services or its agents any
information needed to determine these benefits or benefits for related
services.
Name of Beneficiary
HIC Number
LIFETIME MEDIGAP SIGNATURE AUTHORIZATION
I request that payment of authorized MEDIGAP benefits be made
either to me or on my behalf for any services furnished to me by or in
the Tenet Florida Physicians for any services furnished to me by that
physician/supplier. I authorize any holder of medical information
about me to release any information needed to determine these
benefits for related services.
Name of Medigap Insurer
Name of Beneficiary
Medigap Policy Number
CONSENT FOR MEDICAL SERVICES & TREATMENT
I have been provided with a copy of the SMHCS Notice of Privacy
Practices that describes how Tenet Florida Physicians may use and
disclose my health information, and also describe my rights regarding
my health information.
EVALUATION OR SERVICES AND FOLLOW-UP
I give permission for Tenet Florida Physicians and/or its agent(s) to contact me for the purpose of evaluation the services rendered to me.
 YES
 NO
The undersigned certifies that he/she has read and understands the above, fully accepts all specified terms therein, and has received the
information on patient rights, including the mechanism for initiation, review, and resolution of complaints and a copy of the SMHCS Notice of
Privacy Practices.
I
Signature of Patient of Legally Authorized Representative
Print Name of Patient or Legally Authorized
Representative
Signature of Guarantor of Payment
(state relationship if other than patient)
Print Name of Guarantor of Payment
Signature of Witness
Print Name of Witness
I
Date
I
I
Date
I
I
Date
Authorization and Consent to
Photograph, Record, Interview and Publish Information, Statements or Images
I consent to Tenet Florida Physician Services and the attending physician to photograph or permit other persons to photograph, record,
conduct media interviews, and/or publish information, statements, or images regarding
obtained while under the care of the Hospital.
I
States.
further agree that this information may be used by any affiliate Hospital within the United
(Initial)
I agree that the photographs and/or radio or television broadcast tape may be used in publications or in broadcast format with radio,
television or web sites. I agree that the Hospital and the attending physician may use and permit other persons to use the negatives or
prints prepared from such photographs for such purposes and in such manner as either may deem appropriate. I understand and agree
that the photographs, recording and/or publication may reveal the patient's identity. I agree that the photographs may be used for any
purposes including, but not limited to dissemination to hospital staff, physicians, health professionals and members of the public for
education, treatment, research, scientific, public relations, promotional and charitable purposes and that such dissemination may be
accomplished
in
any manner
and
that
such
use
is
subject
only
to
the
following limitations:
I consent to the taking and use of photographs, recordings, and interviews of me, and to the publication of such photographs,
recordings, and interviews, and to the publication of information, statements or images of or about me, in order to assist scientific treatment,
educational, promotional, public relations and charitable goals. By signing this authorization and consent form, I hereby waive any
right to compensation for such uses, and I and my successors or assigns hereby hold the hospital, its administrators, directors, officers,
employees or agents and related entities, and the attending physician and their successors and assigns harmless from and against any
claim for any injury, and any compensation, resulting from the activities authorized by me in this consent form.
The term "photograph" as used in the foregoing agreement, shall mean motion picture or still photography in any format, as well as
videotape, videodisc and any other mechanical means of recording and reproducing images.
I hereby waive my right under relevant state laws to patient confidentiality with respect to the taking or publishing of any photograph,
record, interview, statement or image of me, as authorized in this consent form, with the exception of those limitations specifically
identified by me in this consent form. I understand that I have the right to revoke this waiver, and to revoke my consent and
authorization in this form, at any time, by notifying the hospital in writing, as discussed herein.
This consent form must be updated if patient condition changes.
By signing below, I acknowledge that I have read and understand the above and agree to the terms of this consent.
Dated:
, 20___ Hour ______ am/pm
Signature:
Patient/Legally Authorized Representative
If signed by other than patient, indicate relationship: ___________________
Authorization to Participate in Media Interview
I authorize to participate in an interview with
and I understand this will involve the disclosure
(Insert name of media)
of health care information about me. I agree to hold ________________________________________ Hospital harmless from any and
all liability arising from this interview and any news article printed or broadcast as a result of the interview.
By signing below, I acknowledge that I have read and understand the above and agree to the terms of this authorization.
Dated:
, 20 _ Hour _________ am/pm
Signature:
Patient/Legally Authorized Representative
If signed by other than patient, indicate relationship: ___________________
Signat ure: ---Witness: Facility/Hospital Representative
Revised 8/02
MEDICAL HISTORY
REVIEW OF SYSTEM FORM
Name: _______________________________________ Date: __________________
Age: _________________ Height: _________________ Weight: _______________
PAST ILLNESSES OF YOURSELF AND FAMILY:
YOU FAMILY
YOU
FAMILY
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ALCOHOLISM
ANEMIA
ASTHMA
CANCER/TUMOR
DIABETES
DIVERTICULITIS
DEPRESSION
EPILEPSY/SEIZURES
GLAUCOMA
HEART DISEASE
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YOU
FAMILY
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HIGH BLOOD PRESSURE
KIDNEY DISEASE
LIVER DISEASE
HEPATITIS
LUNG DISEASE
MIGRAINES
OSTEOARTHRITIS
OSTEOPOROSIS
PHLEBITIS
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STROKE
SUICIDE ATTEMPT
THYROID DISEASE
TUBERCULOSIS
ULCERS
VENEREAL DISEASE
HIGH CHOLESTEROL
HIV/IMMUNE DX
OTHER ___________
RHEUMATICC ARTHRITIS
PAST SURGICAL IIISTORY: (PLEASE INCLUDE DATES)
____________________________________________________________________________________________
REVIEWS OF SYSTEMS - PLEASE CHECK EACH ITEM"YES" AS THEY RELATE TO YOUR HEALTH:
YES
YES
CONSTITUTIONAL:
Weight Loss
Fatigue
Fever

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Eye Pain
Double Vision
Cataracts
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EAR,NOSE,THROAT:
Difficulty Hearing
Ringing in Ears
Vertigo
Sinus Trouble
Nasal Stuffiness
Frequent Sore Throat
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CARDIOVASCULAR:
Murmur
Chest Pain
Palpitations
Dizziness
Fainting Spells
Shortness of Breath
Difficulty Lying Flat
Swelling Ankles
Heat/Cold Intolerance
Wheezing
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SIGNATURE / REVIEWING PHYSICIAN
Gums Bleed Easily
Enlarged Glands
MUSCULOSKELETAL:
SKIN:
Diarrhea
D
Rash/Sores
Constipation
Jaundice
Abdominal Pain
Black or Bloody BM
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Blood in Urine
Erectile Dysfunction
Abnormal Discharge
Bladder Leakage
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Hay Fever
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PSYCHIATRIC:
Mood Swings
Difficulty Sleeping
Muscle Pain
Back Pain
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Lesions
Itching/Burning
NEUROLOGICAL:
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Numbness
Headaches
Tremors
Memory Loss
FEMALES ONLY:
Age Onset Periods _______________
Periods Regular? Yes
ALLERGIC/IMMUNOLOGIC:
Hives/Eczema
Stiffness
Loss of Strength
GENITOURINARY:
Burning/Frequency
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Joint Pain/Swelling
Change in BMs
Nausea/Vomiting
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Bruising
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Heartburn/Reflux
Anxiety/Depression
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GASTROINTESTINAL:
Nighttime
ENDOCRINE:
Loss of Hair
Coughing Blood
Chills
EYES:
Glasses/Contacts
Cough Easy
YES
HEMATOLOGY/LYMPH:
RESPIRATORY:
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No
Number of Pregnancies ___________
How Many Children? _____________
FAMILY HISTORY:
Living or Deceased
Mother
Father
Sibling
Age
Cause of Death
Medical Problems
Medication Taken Regularly (Please include vitamins, hormones, birth control, aspirin,
sleeping tabs, etc.):
NAME
Medication Allergy: __________YES
DOSE
FREQUENCY/TIMES
NO
Name of Medication(s):
BLOOD TRANSFUSIONS
Have you ever had a blood transfusion?
If yes, what year?
SOCIAL:
Smoke: ________YES ________ NO
Drink: ________ YES ________ NO
Drugs: ________ YES ________ NO
Exercise: ______ YES ________ NO
YES
NO
Frequency _______________
Frequency _______________
Frequency _______________
Frequency _______________
Please list below any medical issues we should be aware of: