Patient Forms

Accepts new patients

Medicare Medicaid Workers' compensation Other
Yes Yes Yes Yes

Medical insurance plans and payment options

We file to commercial Blue Cross Blue Shield of NC, Cigna, Tricare, United Healthcare and a number of other private insurance plans. Your contract with your insurance company is unique and its terms are not necessarily disclosed to us accurately or entirely. Please contact your insurance carrier to verify your coverage and out of pocket amounts prior to your appointment to ensure your accurate understanding.

In order to provide you with the most effective and efficient care, payment for service is due at the time service is rendered. For patients for whom we are filing insurance, any amounts for your visit with us that your insurance indicates will be identified as patient responsibility, including but not limited to co-payments, deductibles and co-insurance, are due at the time of service. We accept cash, as well as debit, Visa, MasterCard, and American Express for your convenience. For those looking to pay their medical out-of-pocket costs over time, our office has partnered with CareCredit. We are happy to assist you with completing a CareCredit application. To do so, please contact our office at 910-791-4492. Alternatively, you may complete the application online at

Office information from Derrick G. Hickey, MD

Notice of Privacy Practices
For Informational Purposes Only. You do not need to print or sign this document prior to your first visit.

New Patient Forms Only
New Patient Forms only, without driving directions and welcome letter.

Release Medical Records FROM PCO
Release of information from Port City Orthopaedics to another care provider or, if you are a member of the military, to yourself.

Release Medical Records TO PCO
HIPAA authorization for release of your designated medical records to Port City Orthopaedics.

Requesting MD Referral Form - FOR PHYSICIAN USE ONLY
For Physician Use Only - to refer a patient to our office.


Port City Orthopaedics 5305 Wrightsville Ave, Bldg H Wilmington, NC USA 28403 View map Phone (910) 791-4492 Fax (910) 791-4355

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This website is provided by the American Academy of Orthopaedic Surgeons as a service to its members. All materials on this Web site have been created, developed or assembled by the member physician, who is solely responsible for its content and any permissions necessary to properly place the materials on this website. The AAOS does not review this information nor does it exercise editorial control over it and consequently AAOS is not liable for any damage that may be caused by this information.