Patient Information

New Patient Forms

Download the Dunham Orthopaedics Patient Packet and reduce the time spent in the waiting room. Simply click download and print the forms. Please complete all information to the best of your knowledge. Bring the completed forms with you to your appointment. Also, if you have had previous diagnostic studies like an x-ray, MRI, CT Scan, or EMG please bring a copy of the report and the CD containing any images. This is greatly appreciated and will prevent delays the day of your appointment.

Dr. Rory Dunham’s Patient Packet:

• New Patient Questionnaire Form
• Medication & Allergy Form
• Medication Policy
• Review of System Form
• Insurance Form
• Privacy Notice Form
• Workers Compensation Form
• HIPAA Notice of Privacy Practices
• Financial Policy
• Pharmacy Information
• Appointment Policy
• Disclosure of Physician Ownership

Billing

For information concerning your bill, please contact our billing department at 405.419.8444.

Insurance

Dunham Orthopaedics accepts most major insurance plans. For a comprehensive list of qualified insurance plans and to see if your plan is covered, please call our insurance specialists at 405.759.2562.

• Integris Health Partners
• Medicaid
• Medicare
• Multiplan/PHCS
• Naphcare
• NPPN
• OHN
• OSMA Health
• Pacificare
• PCC
• Rockport
• Secure Horizons
• Tricare Prime
• Tricare Standard
• Triwest
• United Healthcare
• USA MCO
• Workent

Our office is committed to providing you with the best possible medical care. It is our policy that payment is due at the time professional services are rendered. We accept payments in the form of cash, personal checks, VISA and MasterCard.

We will bill most insurance carriers for you if proper paper work is provided to us. You must provide our office with a copy of your insurance card at you initial appointment or you will be responsible for all charges at the time of service. It is your responsibility to familiarize yourself with your insurance policy including the deductible amount and co-payment amount.

If your insurance changes, you must provide our office with an updated copy of your insurance card in order to ensure that our office has a contract with your new insurance carrier. This will also help to prevent denials. We will also bill most secondary insurance companies for you. You will be required to pay any co-pay, deductible or non-covered services each time you are seen.

Medicare

We do accept Medicare Assignment and we will bill Medicare for you. We will also bill secondary insurance carriers for you. All co-payments and/or deductibles are due and payable at the time service is provided.

Workers’ Compensation

If your injury is work-related, we will need the case number, insurance carrier name, adjuster name, telephone number and date of injury prior to your visits in order to obtain authorization to treat you and bill the worker’s compensation insurance company for all charges incurred in our office. If your case is pending or NOT authorized, you are responsible for all charges until a determination has been made regarding your case.

Personal Injury Cases

You are responsible for a $225.00 deposit at the time of service unless other arrangements have been made with our billing office. In some cases we will bill for auto accident or other liability cases. In order to do so, prior to your appointment, we will need the auto insurance/3rd party liability insurance information, including liable party, mailing address for claims, telephone number, policy number/claim number and date of injury. If you are represented by an attorney, we will need your attorney’s name, address and phone number. We will file a lien on any services rendered to you, however, if your case is not settled in a timely manner, you will be responsible for payment in full immediately.

Our payment policy for other family members bringing in a minor are as follows: The person accompanying the minor is responsible for paying the account. If a legal document is involved stating another individual is responsible for paying medical costs, that document is between those individuals involved, and DOES NOT involve our office. You will need to pay for services that day and you will be given an itemized statement from which YOU may be reimbursed.

We do understand that insurance can be very confusing and difficult to understand. If you have any questions, please feel free to ask someone in the business office or call us at 405.759.2562.

Medication Refills & Office Policies

• Refill requests may be made during regular office hours. For refills that can be called in, have the pharmacy fax a request to our office. Refill requests received after 3:00 pm will filled the following work day. Please have refill requests faxed to 405.703.4870.
• Please check your bottles for refills. If you need refills, please call the pharmacy only. You do not need to call the physician’s office.
• Refills will not be made after hours, on weekends or holidays. The on-call physician will not answer calls regarding medication refills.
• Prescriptions that cannot be phoned in require a 24 hour notice to be refilled.
• If a written prescription is to be picked up, you may do so during regular office hours.
• Patients are responsible for their controlled substance medication. You will need to be seen in our office every month for controlled medications as we do not handle long term pain management.
• Please remember to discuss any medication concerns and all refill requests you have with your physician at your regularly scheduled appointments. If you need refills and have an appointment, please request them at the time of your visit.
• If you have a formulary or a preferred medication, you MUST let our office know prior to the physician writing a prescription or calling in your medication. For example, if you want a brand name or need a less expensive medication, let our office know.
• Samples are only available if we have them in stock, there is no guarantee that we will have the drug you may need. We do not stock pain medications!
• If you need a non-emergent referral, you should allow 5 to 7 business days; many insurance companies require this amount of time to return your approved referral.
• There will be a $25.00 charge for completing any forms, (i.e. disability forms, FMLA papers), Please allow 7 to 10 business days for completion of forms.
• Dunham Orthopaedics has a no tolerance policy for rude, unkind or discourteous behavior toward the physician or office staff. In return, our staff is expected to extend kindness and respect to all parties.
• Due to Emergency Call Coverage, we occasionally have to schedule patients on an emergency basis. We apologize for any delay you may experience at your appointment time.
• If you need to request medical records, please be aware it may take 5 to 7 days, but we will make every effort to fulfill all requests as quickly as possible.