DR WHITE HIP ARTHROSCOPY SURGICAL PACKET

Transcription

1 DR WHITE HIP ARTHROSCOPY SURGICAL PACKET PLEASE NOTE THE ATTACHED INFORMATION NEEDS TO BE FILLED OUT AND RETURNED TO OUR OFFICE IN ORDER TO SCHEDULE SURGERY WITH DR. WHITE 1. THE HIP ARTHROSCOPY FINANCIAL CONTRACT WHICH MUST BE SIGNED AND RETURNED IS REQUIRED FOR CASES WHERE THE INSURANCE MAY DENY YOUR SURGERY. FOR QUESTIONS ABOUT THIS YOU MAY CONTACT OUR OFFICE AND SPEAK TO JENNIFER L. OR JACQUE AT AT THE BOTTOM OF THIS PAGE YOU WILL FIND A COPY OF THE CPT CODES FOR THE PROCEDURE. YOU MAY CONTACT YOUR INSURANCE COMPANY WITH THESE CODES TO CHECK YOUR BENEFITS ON OUT-PATIENT SURGERY. DR WHITE DOES NOT HAVE CODES FOR ALL PROCEDURES PERFORMED SO IN MOST CASES A UNLISTED PROCEDURE IS BILLED. 3. ENCLOSED IS A COPY OF OUR SURGICAL ASSISTANT FORM. PLEASE NOTE DR WHITE S SKILLED ASSISTANTS, CHRIS IRONS OR JOE HARRIS, ARE NOT CONTRACTED WITH ANY INSURANCE COMPANIES SO THEY ARE CONSIDERED OUT OF NETWORK. IN MOST CASES THEY ARE ABLE TO GET PAID BY THE INSURANCE HOWEVER WE DO REQUIRE YOU TO READ AND SIGN OUR AGREEMENT WITH THEM ON BALANCE BILLING PATIENTS ON ANY DENIED CLAIMS. 4. WE HAVE ALSO INCLUDED 2 PAGES TO BE FILLED OUT THAT DR. WHITE REQUIRES FOR ALL HIS PATIENTS. PLEASE COMPLETE THESE 2 FORMS (PRESERVATION STUDY SHEET & LOWER EXTREMITY FUNCTIONAL SCALE) FOR YOUR HIP PAIN AT IT S WORST PRIOR TO SURGERY. ALSO INCLUDED IS A PAIN MEDICATION CONTRACT. PLEASE MAIL AND/OR FAX TO: 1830 FRANKLIN STREET SUITE 450 DENVER CO FAX: 303/ FEMOROPLASTY (shaving of the femur head) ACETABULOPLASTY (rim trimming) LABRAL REPAIR (for simple repairs with sutures) UNLISTED ARTHROSCOPIC PROCEDURE (labral reconstruction, iliopsoas release, micrfracture of the acetabulum, windowing of the IT band, greater trochanteric bursectomy or any other procedure done arthroscopically that does not yet have a code).

2 HIP ARTHROSCOPY FINANCIAL CONTRACT The procedure you are about to undergo is called Arthroscopy of the Hip with management of Femoracetabular Impingement and Labral Reconstruction. Currently, all aspects of this type of surgery have not been fully coded by the American Medical Association. As a result, when we bill your insurance company, we may use an unlisted procedure code to describe portions of the surgery which have not yet been given a code. Since we are forced to use an unlisted procedure code to describe all of the work that will be put into your hip, insurance companies frequently pay only a small portion of our bill or on occasion pay nothing at all. This is a comprehensive procedure designed to reshape your hip joint and requires advanced training and 3-4 hours of surgery. Our fees for these services are as follows: $10,000 - $25,000 depending on the complexity of the surgery Our office will work diligently to get your insurance to pay at least $5,000 for this service. However, if they do not pay, we will expect you to be responsible for Dr. White s services. In the case your insurance does not pay for your surgery, we are willing to offer you the following reduced fee: $5,000 for Dr. White s professional services Due to our current situation with insurance reimbursements with Aetna, Cigna, UHC, Rocky Mountain Healthcare, and Humana, we expect a 50% deposit prior to your surgery date if this is your insurance carrier. If your insurance pays the claim and you do not have any financial obligation due to your insurance policy, we will refund you. However, if they retract that decision and recoup our funds we will be forced to balance bill you. We will therefore collect $2, as your deposit towards your surgery and expect the remaining balance to be paid within 6 months of your surgery date. If you have any questions regarding this, please ask prior to your procedure. Please indicate below that you understand the above and you allow Western Orthopaedics to hold you responsible for payment of the Expected Payment amount. I, the undersigned (or as legal guardian of the patient), understand the above and allow Western Orthopaedics to hold me responsible for the expected amount as above. Print Patient Name Patient or Patient Guardian Signature Surgery Date Date

3 REVISION HIP ARTHROSCOPY FINANCIAL CONTRACT The procedure you are about to undergo is a revision Arthroscopy of the Hip with management of Femoracetabular Impingement and Labral Reconstruction. Currently, all aspects of this type of surgery have not been fully coded by the American Medical Association. As a result, when we bill your insurance company, we may use an unlisted procedure code to describe portions of the surgery which have not yet been given a code. Since we are forced to use an unlisted procedure code to describe all of the work that will be put into your hip, insurance companies frequently pay only a small portion of our bill or on occasion pay nothing at all. This is a comprehensive procedure designed to reshape your hip joint and requires advanced training and 3-4 hours of surgery. Our fees for these services are as follows: $10,000 - $25,000 depending on the complexity of the surgery Our office will work diligently to get your insurance to pay at least $7,000 for this service. However, if they do not pay, we will expect you to be responsible for Dr. White s services. In the case your insurance does not pay for your surgery, we are willing to offer you the following reduced fee: $7,000 for Dr. White s professional services Due to our current situation with insurance reimbursements with Aetna, Cigna, UHC, Rocky Mountain Healthcare, and Humana, we expect a deposit prior to your surgery date if this is your insurance carrier. If your insurance pays the claim and you do not have any financial obligation due to your insurance policy, we will refund you. However, if they retract that decision and recoup our funds we will be forced to balance bill you. We will therefore collect $3, as your deposit towards your surgery and expect the remaining balance to be paid within 6 months of your surgery date. If you have any questions regarding this, please ask prior to your procedure. Please indicate below that you understand the above and you allow Western Orthopaedics to hold you responsible for payment of the Expected Payment amount. I, the undersigned (or as legal guardian of the patient), understand the above and allow Western Orthopaedics to hold me responsible for the expected amount as above. Print Patient Name Patient or Patient Guardian Signature Surgery Date Date

4 Precertification Questions MRN#: Name: Date: Please answer the following questions in order to help us obtain precertification/pre determination of your upcoming surgery: Have you done any physical therapy? Yes No How long? Where? Conservative therapy and how long (rest, ice, activity modification) : Have you taken any anti inflammatories or Tylenol? Yes No How long, specifically, have you been taking them (not just as needed)? Did you develop any issue/side effects from taking it? Please indicate what dosage and frequency:

5 Hip Preservation Study Sheet- Brian J. White MD Name: Date: Before surgery Already had surgery: 6 weeks ago 3 months ago 6 mos ago 1 year ago More than 1 year, please specify: Modified Harris Hip Score: Please select the one response that best reflects your pain: 1. None or you ignore it. 2. Slight, occasional, no compromise at all 3. Mild, no effect on average activities 4. Moderate pain, tolerable but concessions to pain are made. Some limitation of ordinary activity or work. May require pain medication stronger than aspirin. 5. Marked pain, serious limitation of activity. 6. Totally disabled, crippled, pain in bed, bedridden After 6-9 blocks (about 1 mile), please describe how you would walk: (Please select only one response) 1. No limp 2. Slight limp 3. Moderate limp 4. Severe limp Which one response best reflects how far you can walk? Unlimited 6 Blocks 2-3 Blocks Indoors only Bed and Chair Which kind of support do you use when you walk? (Please select only one response) 1. None 2. Cane for long walks 3. Cane most of the time 4. One crutch 5. Two canes 6. Two crutches 7. Not able to walk Which one response best reflects your ability to go up and down stairs? 1. Normally without using a railing 2. Normally using a railing 3. In any manner 4. Unable to use stairs. How can you put on your socks and shoes? (Please select only one response) 1. With ease 2. With difficulty 3. Unable Which one response best reflects your ability to sit? 1. Comfortably in an ordinary chair for one hour 2. On a high chair for one-half hour 3. Unable to sit comfortably in any chair Are you or would you be able to use public transportation? Yes 2. No VAS Scale: Please rate your pain at rest on a scale from 1 (none) to 10 (severe): Please rate your pain with daily activities: Please rate your pain with your athletic activity: Please rate your level of satisfaction with your surgery. 1-not satisfied, 10-very satisfied not satisfied at all very satisfied

6 Section 1: To be completed by patient LOWER EXTREMITY FUNCTIONAL SCALE 1 Name: Age: Date: Preop 6 mos postop 1 year postop Other: Section 2: To be completed by patient We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity. Today do you, or would you have difficulty at all with: (Circle one number on each line) Extreme Difficulty or Unable to Perform Activity Quite a bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty a. Any of your usual work, housework or school activities b. Your usual hobbies, recreational or sporting activities c. Getting into or out of the bath d. Walking between rooms e. Putting on your shoes or socks f. Squatting g. Lifting an object, like a bag of groceries from the floor h. Performing light activities around your home i. Performing heavy activities around your home j. Getting into or out of a car k. Walking 2 blocks l. Walking a mile m. Going up or down 10 stairs (about 1 flight of stairs) n. Standing for 1 hour o. Sitting for 1 hour p. Running on even ground q. Running on uneven ground r. Making sharp turns while running fast s. Hopping t. Rolling over in bed COLUMN TOTALS: Section 3: To be completed by provider SCORE: out of 80 (No Disability 80, SEM 5, MDC 9) Initial FU weeks 1 adapted from Binkley J et al; Phys Ther; 79: , 1999.[Prepared Feb 01]

7 CONTROLLED SUBSTANCE PRESCRIPTIONS So that we may provide you with the highest quality care, the following contract must be agreed upon to assure a productive doctor/patient relationship. PAIN MEDICATIONS: 1. If during the course of your treatment at our clinic, you require surgery, a maximum of two pain medication prescriptions will be prescribed to you preoperatively and a maximum of three prescriptions will be prescribed postoperatively. In the unlikely case you require more than three prescriptions post operatively; you agree to follow up with a primary care physician or a pain management specialist. 2. Medications should be taken only as prescribed. Medications used in greater quantities than the amount prescribed will not be refilled until the planned renewal date. If you experience any side effects, please notify our office at once. I have read, understand, and accept the contract and understand the same has been explained to me by Brian White, M.D. Patient Signature: Date: Medical Record No: Witness Signature: Date:

8 HIP ARTHROSCOPY SURGICAL ASSISTANT NOTIFICATION FORM Please be informed that a surgical assistant S.A. or a Physician Assistant P.A. will be required for the proper performance of the operation you need. Surgical assistants and Physician Assistants are professional members of the health care team, and are qualified by academic and clinical education to provide assistance to your surgeon during surgery. If your doctor feels that an assistant is necessary for your procedure, he will use one (some procedures require two assistants), even if your insurance company does not recognize this as a medical necessity. The insurance company will be billed first at 75% of the surgeon s fee. If your insurance company denies the assistant surgeon, (per our agreement) the maximum you are required to pay (for Chris Irons or Joe Harris) is $600. Note: Most insurance companies consider assistant surgeon s out of network providers or will not even contract with an assistant surgeon. Chris Irons and Joe Harris are out of network for all insurance companies. Once you receive a bill from the outside surgical assist company please direct any questions to their billing department. Again the assistant surgeon company is aware of the above agreement and will correct your bill accordingly. Please do not contact our billing department regarding an outside surgical assistant. Chris Irons biller is Mandy and she can be reached at Joe Harris (Dependable Surgical Assistants) biller is Kati and she can be reached at I have read the preceding information and acknowledge being notified. Patient signature: Printed name: Today s date: REV 11/09/16

9 SURGERY CANCELLATION NOTICE Due to the complex nature of booking this procedure we have found it necessary to implement an administrative fee for those who cancel their surgery with less than a two week notice. (This is only for non medically documented cancellations, if you have a doctor s note we will waive this fee). We will swipe the patient s card when the surgery is scheduled and keep the information stored in a secured credit card vault. Upon a late cancellation we will charge a $ fee to the card. I have read and agree to the late cancellation fee: PRINT: SIGNATURE: DATE: MR#:

10 PORTER ADVENTIST HOSPITAL Map & Directions Street Address 2525 S. Downing St. Denver, CO THORNTON DENVER INTERNATIONAL AIRPORT Phone Numbers Main: ARVADA Scheduling: GOLDEN LAKEWOOD DENVER AURORA Traveling from the North: Traveling on I-25 north, take exit 203 for Evans Ave. Turn left onto Evans. Ave LITTLETON Turn left onto S. Downing St. HIGHLANDS RANCH CENTENNIAL PARKER Porter Adventist Hospital will be on the right. S. DOWNING ST. S. UNIVERSITY BLVD. S. COLORADO BLVD. Traveling from the South: Traveling on I-25 south, take exit 206 toward Washington St./Emerson St. S. SANTA FE DR. S. BROADWAY PORTER ADVENTIST HOSPITAL BUCHTEL BLVD. YALE AVE. EVANS AVE. YALE AVE. Keep right at the fork, follow signs for Washington St./Emerson St. and merge onto Buchtel Blvd. south. Turn right onto S. Downing St. Porter Adventist Hospital will be on the right. DARTMOUTH AVE. HAMPDEN AVE South Downing Street Denver, CO Phone: porterhospital.org/radiology

11 PORTER ADVENTIST HOSPITAL Ground Floor Map EMERGENCY DEPARTMENT ENTRANCE Medical Imaging Patients Enter hospital through Main Entranace and proceed to the Registration Desk. After registration, go down main hallway and turn left. Proceed down hallway going past elevator bank and turn left at the end of the hall. Medical Imaging department will be on the left side. REGISTRATION LOBBY MEDICAL IMAGING MAIN ENTRANCE VALET PARKING MRI Patients Enter hospital through Cancer Center Entrance. Proceed through the Cancer Center atrium and go through the sliding doors. Turn right and proceed down hallway. MRI will be on the left side. MRI CANCER CENTER ENTRANCE PARKING GARAGE Central Scheduling: Radiology Department: Fax: South Downing Street Denver, CO Phone: porterhospital.org/radiology

12 ASPIRIN/BLOOD THINNER PROTOCOL FOR PATIENTS NORMALLY TAKING COUMADIN, WHO HAVE NOW BEEN ASKED TO SUBSTITUTE WITH LOVENOX IT IS REQUESTED THAT YOU DISCONTINUE THE LOVENOX A MINIMUM OF 24 HOURS PRIOR TO SURGERY, OR THERE IS A POSSIBILITY YOUR SURGERY WILL BE CANCELLED. DO NOT TAKE ASPIRIN OR ASPIRIN RELATED PRODUCTS FOR TWO (2) WEEKS PRIOR TO YOUR SURGERY - BELOW IS A LIST FOR YOUR CONVENIENCE. The taking of aspirin and/or aspirin related medications can prove harmful to your body's perioperative healing process. Aspirin chemically inhibits the ability of the body to form stable clots necessary to permit proper healing. If you are currently taking any medication and are unsure as to whether it contains aspirin or has a similar effect as aspirin (preventing the formation of stable blood clots), please do not hesitate to contact your pharmacist for additional information. 4-Way Cold Tabs Actron Advil Caps and Tabs Aleve Alka Seltzer Plus Night-Time Cold Medicine Alka Seltzer Plus Cold Medicine Alka Seltzer Extra Strength Alka Seltzer (Flavored) Alka Seltzer Antacid/Pain Reliever Anacin Analgesic Caps & Tabs Anacin Maximum Strength Tabs Anacin Arthritis Pain Formula Anaprox Ansaid Ascriptin w/codeine Tabs Axotal B-A-C #3 Tabs Bayer Aspirin Tabs & Caps Bayer Maximum Aspirin Tabs & Caps Bayer 8 Hour Time Release Aspirin Bufferin Analgesic Tabs Bufferin Arthritis Strength Tabs Carisoprodol Compound Tabs Cataflam Children's Chewable Aspirin

13 Clinoril N-saids Damason-P Norgesic Forte Tabs Darvon with ASA Norgesic Tabs Darvon-N with ASA Nalfon Daypro Nabumetone Dia-Gesic Improved Naprelan Diclofenac Sodium Potassium Naproxen Disalcid Naproxen Sodium Dolobid Naproxyn Dolobid #3 Tabs Nuprin Tabs Easprin Orphengisc w/caff & Aspirin Ecotrin Orudis Ecotrin Max Strength Tabs Oxycodone w/aspirin tabs Empirin with Codeine Oruvail Equagesic Tabs Oxaprozin Etodolac Percodan Tabs & Demi Tabs Feldene Persistins FenoproFen Piroxicam Fiogesic Tabs Regular strength tabs Fiorinal Tabs & Caps Relafen Fiorinal with Codeine Caps Robaxisal Tabs Geiprin Tabs Roxiprin Tabs Ibuprofen Tabs Rulen Tabs Indocin Salflex Indomethacin Salicylate s Ketoprofen Soma Compound Tabs w/codeine Lodine Soma Compound Tabs Lortab ASA Tabs Sulindac Medipren Tabs & Caps Supac Midol 200 Synalgos DC Tabs Motrin Talwin Motrin 200 Talwin Compound Motrin Tabs Tolmetin Mobic Tolectin Meloxicam Tolectin DS or 600 Trilisate Vanquish Analgesic Caps You may take Tylenol, Anacin 3 or Datril as they do not contain aspirin. Attention Men: Please discontinue any erectile dysfunction medications 1 week prior to surgery.

14 Monday, Oct. 09, 2000 A Dangerous Mix By Ian K. Smith, M.D. Doctors have never quite figured out what to say about herbal supplements. While alternative medications have become increasingly popular--americans will spend some $5 billion this year on natural remedies for everything from arthritis to the common cold--most physicians assumed that even if they didn't know exactly what these remedies did, they were, at worst, harmless. But more and more, doctors are starting to recognize that many natural supplements have medicinal qualities that can complement--or conflict with-- the treatments and medications they prescribe. The American Society of Anesthesiologists is the latest physicians' group to sound a warning about the potential side effects of alternative medications. Concerned by evidence that some supplements can interfere with anesthesia, the group has issued a recommendation that patients stop taking all natural remedies at least two weeks before surgery--giving the body plenty of time to clear them from the system. The anesthesiologists' warning is based on the latest of several findings that are raising doctors' awareness of the risks associated with natural supplements. Take, for instance, ginkgo biloba, used by almost 11 million Americans to improve memory and increase blood circulation. Doctors now believe ginkgo may reduce the number of platelets in the blood and can prevent blood from clotting properly. Taking ginkgo at the same time one is taking blood-thinning medications, like Coumadin or even aspirin, could make a patient dangerously vulnerable to bleeding. Similarly, St. John's wort, a popular supplement taken to treat anxiety, depression and sleep disorders, is believed to prolong or increase the effects of some narcotic drugs and anesthetic agents. Ginseng, an herb taken to boost vitality, has been associated with high blood pressure and rapid beating of the heart-- conditions that could be deadly in the operating room. Part of the problem is that herbal supplements and mainstream medicine come from two very different worlds and operate in different regulatory environments. The marketing of prescription and over-thecounter drugs is strictly regulated by the Food and Drug Administration, which requires scientific proof of safety and efficacy. Herbal remedies, by contrast, are largely exempt from FDA supervision. Companies can sell herbal preparations without guaranteeing that what's on the label is inside the bottle. These uncertainties don't mean that you should never take a supplement. But they make it even more important that you discuss whatever you are taking with your physician--something not enough patients do. A recent study showed that although 60 million Americans have taken alternative medicines, only a third of them reported it to their doctors. This is a bad idea. A drug your doctor prescribes could be perfectly safe and effective, but if you are taking a similar-acting supplement, there is a real danger of cross-reaction. Don't be afraid to bring your herbal supplements to your doctor's office. Your physician may spot a potential conflict on the label or know of another drug--or even another supplement--that works just as well. Dr. Ian appears on WNBC-TV in New York City. him at ianmedical@aol.com For more on herbals, try altmed.od.nih.gov Find this article at:

15 Herbal Supplement Instructions IF YOU ARE TAKING ANY OF THESE HERBAL SUPPLEMENTS (LISTED BELOW), WE ASK THAT YOU STOP TAKING THEM 2 WEEKS PRIOR TO YOUR SURGERY. ECHINACEA EPHEDRA GARLIC THIS DOES NOT MEAN GARLIC IN YOUR FOOD. GINKGO GINSENG KAVA ST. JOHN S WART VALERIAN FLAX SEED OIL, VITAMIN E AND FISH OIL ANY TYPE OF DIET PILLS (METABOLIFE, HERBALIFE, ETC) IT WAS RECENTLY REPORTED THAT THESE HERBAL SUPPLEMENTS MIGHT CAUSE HARM DURING AND/OR AFTER SURGERY. THANK YOU FOR YOUR COOPERATION AND ALLOWING US TO KEEP PROVIDING YOU WITH THE BEST CARE.

16 Preoperative Evaluation: This is required for all patients having surgery. A history and physical examination (H&P) 14 to 21 days prior to procedure. This is done to make sure you are medically cleared to undergo surgery. Please allow 2 days for the paperwork and labs results to be processed. You will need to notify us of when you have scheduled this appointment. You should remember to bring a list of all medications you are currently taking including any over the counter medications. The lab request does not require any fasting (not eating). If you are over 50 years old there are additional test that are ordered such as EKG or Chest X ray. WHAT TO WEAR: Loose fitting clothing, sweats for colder weather, and summer dresses work well in warm weather. WHAT TO BRING: This is a 23 hour observation surgery. You will be in the hospital overnight. Crutches, any medications you might need to take, (bring in original bottle). PLEASE AVOID APPLYING ANY LOTION S OR BODY OIL S IN THE HIP AREA THE DAY OF SURGERY. CALL PRE ADMIT TO PRE REGISTER prior to you surgery date DR. WHITE HAS A VERY INFORMATIVE SLIDESHOW ON OUR WEBSITE THAT WILL ANSWER MANY OF YOUR QUESTIONS ABOUT RETURNING TO WORK AND WHAT TO EXPECT FOR YOUR RECOVERY. REMEMBER WHEN IN DOUBT PLEASE DO NOT HESITATE TO CALL OUR OFFICE Please call Jennifer L. 2 weeks prior to your surgery date to confirm. Any surgery cancelled less than 2 weeks prior, is subject to $ cancellation fee. Surgery time subject to change. THANK YOU!

17 Pre Surgical Instructions/FAQs When Should I stop eating and drinking? NO SOLID FOOD AFTER MIDNIGHT, The night before your surgery. IF YOUR SURGERY IS SCHEDULED FOR: 7:00am nothing past MIDNIGHT 11:30am nothing past midnight 2:30pm clear liquids ONLY until 7:30am (clear liquids, anything you can see through this can include coffee (no cream or sugar) Why is this important? Prevention of a serious anesthesia complication such as Aspiration (inhaling stomach contents into lungs) If you Do not follow the recommendations above, the anesthesiologist or surgeon can and will cancel your surgery Check in time for your surgery: 7:00am check into surgery admissions at 5:00am 11:30am 2:30pm check into surgery admissions at 6:30am check into surgery admissions at 10:15am MEDICATIONS TO AVOID: You will be given a list of medications to avoid Any questions please call Dr. White s office

18 Dear Patient, Dr. White has ordered a VenaPro (DVT prevention) and an IceMan Clear3 (cold therapy to reduce pain and swelling) units to be used following your upcoming surgery. Most insurance companies view these devices as not medically necessary therefore they do not pay for the units. Total Orthopedics, Inc S. Wadsworth Blvd. Littleton CO Phone: Fax: Dr. White has arranged for you to purchase both units with special discounted pricing through DJO Global. Your total cost to purchase both the VenaPro and the IceMan Clear3 with an appropriate pad is $ plus sales tax. Call for pricing on items sold separately. **IF NOT ORDERED IN TIME FOR SHIPPING TO YOU, UNITS WILL BE DELIVERED TO THE HOSPITAL THE DAY AFTER YOUR SURGERY** Please contact Connie with any questions or concerns at or cweber@totalortho.net. Visit to learn more about the products. Thank you, Total Orthopedics, Inc. Patient Name Billing Address Telephone(s) address for receipt Date of Surgery Method of Payment: AMEX DISC MC V Card Number Expiration Date Security Code (3 or 4 digits) Name on Card Physician Signature Date BRIAN WHITE, MD NPI My signature above means that, in my judgment, the above prescribed products are medically indicated, necessary, and consistent with current accepted standards of medical practice and treatment of this patient s physical condition. **IF NOT SHIPPED TO YOU, UNITS WILL BE DELIVERED TO THE HOSPITAL THE DAY AFTER YOUR SURGERY** FAX TO (303) THANK YOU

19 ICEMAN COOLING MACHINE AND VENAPRO LEG COMPRESSION DEVICE- COST $ VENAPRO

20 What is a CPM? Continuous Passive Motion (CPM) is a postoperative procedure designed to aid in the recovery of the joint after surgery. If a patient fails to move their joint tissue after extensive joint surgery, the joint will become stiff and scar tissue will form, resulting in a joint with limited range of motion which often takes months of physical therapy to recover. What a CPM Machine Does Passive range of motion means that the joint is moved without the patient s muscles being used. Continuous passive motion devices are used after surgery, both in the hospital and in the home. The motorized CPM device gradually moves the affected joint through a prescribed range of motion for an extended period of time. A CPM s Clinical Benefits The device significantly accelerates recovery time by: Decreasing soft tissue stiffness Increasing range of motion Promoting healing of joint surfaces and soft tissue Preventing the development of motion-limiting adhesions (scar tissue) Our Procedure for Set Up: After receiving the prescription, benefits are verified with insurance. The patient will be contacted the week prior to surgery regarding benefits and out of pocket expenses. The order will be assigned to a tech and they will contact the patient and set up an appointment for delivery of the CPM. Patients will have the CPM for the prescribed amount. Our Procedure for Pick Up: When the patient is done, they will contact our office for a pick up. Picture 1 Picture 2 Picture 2 is the machine with the pads, giving a better idea of how it is used. Total Orthopedics / KINEX Medical Company 4700 S Wadsworth Blvd Littleton, CO Phone:

21 Right of Refusal for Durable Medical Equipment Dr. White recommends the use of the following after surgery: CPM or bending machine: This is used to keep the joint moving in the first 2 3 weeks after surgery to minimize scarring that can make the joint feel tight. Ice Machine: This helps reduce early inflammation and pain. SCD s or compression stockings machine: These intermittently squeeze the calf muscles and decrease the risk of blood clots. Unfortunately, insurance companies frequently do not cover the expense of these. Dr. White has worked hard to negotiate the best possible financial arrangement for you. However, given the potential financial burden, it is your choice if you decide not to use them. Please sign below that you are responsible for making this decision. If you are refusing this equipment, please send or fax this form back to me at Patient Signature: Date: Printed Name:

22 Your anesthesiologist will make every effort to contact you the night before your surgery. Please assist us by ensuring that your contact information is correct and your phone will accept blocked calls. If for some reason we are unable to reach you, please visit our website or call our office at with questions. Thank you and we look forward to caring for you! Revised April 2015