Nebraska Orthopaedic Center | Patient Information

Patient Paperwork for Satellite Clinics

If your appointment is at our Main Lincoln Offices {575 South 70th Street, Suite 200 (North Office) or 6900 A Street (South Office) } you’ll receive a text message or email to complete your paperwork.
Patient Information
Patient Name*

First NameMiddle NameLast Name
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Age*
Example: 23
Patient Date of Birth*

MonthDayYear
Patient Gender*
Martial Status*
Social Security Number
Primary Phone *
Please enter a valid phone number.
Primary Phone is:*

HomeMobile
Secondary Phone
Please enter a valid phone number.
Secondary Phone is:*

HomeMobileWorkOther
E-Mail Address*
Enter "None" if no email.
Race *
Ethnicity *
Language*

EnglishSpanishOther
Employment Status *
Employer Name*
Occupation*
Employer Address *

Street Address

CityState / Province

Postal / Zip Code
High School/College Name *
Spouse's Name *

First NameLast Name
Spouse's Phone *
Please enter a valid phone number.
Spouse's Employment Status *
Employer Name*
Emergency Contact Name*

First NameLast Name
Relationship*
Primary Phone *
Please enter a valid phone number.
Were you referred to Nebraska Orthopaedic Center?*

YesNo
By whom?*

ProviderSelf-ReferralUrgent Care/ERFriend/Family
Referring Provider Name*
Family Doctor*
Ie. Physician/PA-C/APRN First and Last Name
Patient Medical Insurance Information
Do you have medical insurance?*

YesNo
Primary Insurance *
Policy Holder*
Policy Holder's Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Is the policy holder's address the same as the patient?*

YesNo
Policy Holder Address*

Street Address

CityState / Province

Postal / Zip Code
Policy ID #*
Group #
Policy Holder's Employer*
Policy Holder's Social Security #
Do you have secondary insurance?*

YesNo
Secondary Insurance *
Policy Holder*
Policy Holder's Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Is the policy holder's address the same as the patient?*

YesNo
Policy Holder Address*

Street Address

CityState / Province

Postal / Zip Code
Policy ID #*
Group #
Policy Holder's Employer*
Policy Holder's Social Security #
Responsible Party (if patient is a minor)
Name*

First NameMiddle NameLast Name
Is this address the same as the patient?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone *
Please enter a valid phone number.
Primary Phone is:*

HomeMobile
Secondary Phone
Please enter a valid phone number.
Secondary Phone is:*

HomeMobileWorkOther
Employer*
Relationship to Patient*
Patient Information
Height*
Weight in pounds*
Race *
Ethnicity *
Language*

EnglishSpanishOther
Preferred Pharmacy Name*
Example: CVS
Pharmacy Address*

Street Address- Example: 14th & Superior

Street Address Line 2

CityState / Province

Postal / Zip Code
Location of the Problem
Please indicate the location of your primary complaint: Side of Body:*

LeftRightBilateral (Both)
What body part?*
Location of the symptoms*

FrontBackInsideOutsideTopBottom
Dominant Hand*

LeftRightAmbidextrous
Injury History
Is what we are seeing you for today due to an injury?*

YesNo Injury (Gradual Onset)
Date of Injury*

MonthDayYear
Date
Where did the injury occur?*

Work Related InjuryAuto/LiabilitySport InjuryOther
How did the injury occur?*
What sport were you playing?*

FootballBasketballBaseballSoftballSoccerHockeyGymnasticsTennisGolfLacrosseTrack/FieldOther
When did you first notice symptoms?*
Pain History
Rate the pain*

0

1

2

3

4

5

6

7

8

9

10

0 is Less Pain, 10 is Most Pain
Rate the pain at its best*

0

1

2

3

4

5

6

7

8

9

10

0 is Less Pain, 10 is Most Pain
Does the pain radiate?*

YesNo
Pain radiate from/to? (ex. low back to right leg)
How would you describe the symptoms?*

AchingBurningDullSharpStabbingThrobbing
How often are the symptoms present?*

Off and onMost of the timeAll the time
Is the problem getting better or worse?*

Getting betterGetting worseUnchanged
Do you have any other additional complaints?*

CatchingClickingDecreased ROMInstabilityGrindingNighttime DiscomfortPoppingSwellingWeaknessLimpingLockingStiffnessSnapping
Do you experience any numbness of tingling?*

YesNo
Where is the numbness or tingling located?*

NeckLow BackUpper ArmShoulderElbowWristHandFingersHipThighKneeLower LegAnkleFootToes
What makes the symptoms better?*

NothingBending OverChanging PositionsElevationLying DownSittingStandingWalkingStretching
Treatment/Testing

Please indicate any prior tests for this problem
Did you have emergency room treatment?*

YesNo
What emergency room?*
Have you had an MRI (Magnetic Resonance Imaging)?*

YesNo
Date of MRI (Magnetic Resonance Imaging)?*

MonthDayYear
Date
Where was your MRI taken?*
Have you had an x-ray?*

YesNo
Date of x-ray?*

MonthDayYear
Date
Where was your x-ray taken?*
Have you had an CT (Computed Tomography) Scan?*

YesNo
Date of CT (Computed Tomography) Scan?*

MonthDayYear
Date
Where was your CT (Computed Tomography) Scan taken?*
Have you had a Dexa?*

YesNo
Have you had a Bone Scan?*

YesNo
Have you had an Ultrasound?*

YesNo
Have you had a Nerve Test (EMG/NCS)?*

YesNo
Where did you have a Nerve Test (EMG/NCS) at?*
Have you been seen by another provider for this problem?*

YesNo
Provider Name:*
Have you received any treatment for this problem (ie. medication, therapy, injections, etc.)?*

YesNo

Have you ever had surgery on this body part?*

YesNo
Type of surgery:blanks*Date of surgery: Date Name of Surgeon: Type a label
Medical Questions
Mark all that currently apply:*

NoneHome oxygenSleep ApneaTaking blood thinnersDialysisPacemaker
Is the patient diabetic?*

YesNo
Patient's last HbD A1c was:*
Any previous complications?*

NoneNeuropathyWound problemsDecreased blood flowEye complicationsKidney complicationsSkin issues
Have you or anyone in your family ever had a reaction to Anesthetic (General or Local)? Please select below.
Causing Malignant Hyperthermia (High Fever)?*

YesNo
Relationship*

SelfMotherFatherSiblingChild/Children
Have you ever had a surgical procedure?*

YesNo

Family History

Have any direct relatives had any of the following disorders?*

	Father	Mother	Siblings
None
Diabetes
Heart Disease
Hypertension
Bleeding Problems
Epilepsy
Connective Tissue
Muscular Dystrophy
Stroke
Osteoporosis
Rheumatoid Arthritis
Cancer
Other

Social History
Do you smoke tobacco?*

YesNoFormer Smoker
How many packs a day?*

0-1 pack/day1-2 packs/day2+ packs/day
Year Started ?*
Year Quit?*
Do you drink alcohol?*

YesNo
How often?*

DailyOccassionallyRarely
Recreational Drug Use*

YesNo
What and how often? *
Are you currently working?*
Occupation*
Employer*
Do you have any work restrictions? (Lifting, prolonged sitting, etc.)*

YesNo
Please list work restrictions (lifting, prolonged sitting, etc.)*
What year did you retire?*
School Name*
Do you participate in sports?*

YesNo
Please list which ones:*
Medications
Do you currently take any medications? Including prescribed or over-the-counter.*

YesNo
Please list ALL medications OR upload a file. If you upload a file please type, "Upload" in Medication box. *
Please upload your medication list or pictures of bottles.

Cancelof
Allergies
Do you have an allergy to Latex?*

YesNo
Do you have any allergies?*

YesNo
Please list ALL allergies with severity and reaction. *
Please select if you have any of the following current medical conditions:*

AneurysmAngina (Chest Pain)ArthritisAsthmaAnxietyBone or Joint InjectionsBursitisCancerCeliac DiseaseChemotherapy/RadiationCongestive Heart FailureCOPDCrohn's DiseaseDiabetesDiverticulitisBlood Clotting DiseaseDepressionEmphysemaEpilepsyFibromyalgiaGoutHeart AttackHepatitisHIV/AIDSHigh CholesterolHigh Blood PressureHyperthyroidismHypothyroidismKidney DiseaseKidney StonesLiver DiseaseAlcohol AddictionMigrainesMRSA InfectionMultiple SclerosisOsteoporosisPacemakerPulmonary Embolism (PE)Bleeding DisorderReaction to AnesthesiaSeizuresSerious IllnessSerious InjuriesStomach UlcersStroke/TIATuberculosisDrug AddictionOther
Aneurysm- Where?*
Type of Cancer?*
Type of Diabetes?*
Type of Hepatitis?*
Please list Other here:*
Patient Signature*

Clear
Date Signed*

MonthDayYear
Date
Patient/Guardian Signature*

Clear
Driver's License/ Photo ID MUST add front and back

Cancelof
Insurance Card MUST add front and back

Cancelof

Authorization to Release Information, Consent to Treatment & Assignment of Benefits
Patient Name*

First NameLast Name
***For Office Use Only***

Patient Account Number:__________
I certify that the information that I have reported with regards to my insurance coverage is correct.

I hereby authorize NEBRASKA ORTHOPAEDIC CENTER, P.C. to file claims and release any medical information necessary to process these claims. I also authorize payments to be made directly to NEBRASKA ORTHOPAEDIC CENTER, P.C. for the services provided to me (or the above-named patient), and authorize NEBRASKA ORTHOPAEDIC CENTER, P.C. to render appropriate treatment/procedures relating to the diagnosis.

I understand that I am financially responsible to NEBRASKA ORTHOPAEDIC CENTER, P.C. for the services provided to me or my dependent. I agree to pay the full amount of all charges incurred by the above-named patient that are not covered by my insurance carrier. I also agree to pay the cost of collection and/or court costs and reasonable fees should this be required.

I understand and agree that any cellular or land line phone numbers and email addresses provided by myself to this office and to any of our services providers, including but not limited to, third party debt collectors, now and in the future, may be used as a means to contact me for any reason, including but not limited to, billing and collecting payment, and that this office and our service providers may leave messages for me manually and by using automatic systems such as by artificial or prerecorded voice. I also agree that this office and any service providers may contact me by sending text messages and emails to any phone number or email address I provide to this office or service providers, and I consent to receive such text messages and emails which may identify the name of this office or service provider sending the communication, and which may disclose the nature of the communications. In the future, should I acquire a new or different cellular, landline or email address, I agree that this consent would stay effective.

I agree that Nebraska Orthopaedic Center, P.C. may request and use my prescription medication history from other healthcare providers or third-party pharmacy benefit payers for treatment purposes.
Date

MonthDayYear
Date
Signature

Clear
I hereby authorize Nebraska Orthopaedic Center, PC to appeal all claims for charges I will incur as a patient of this practice.
Date

MonthDayYear
Date
Signature

Clear

Receipt of Notice of Privacy Practices
I was given the opportunity to receive a copy (Nebraska Orthopaedic Center Notice of Privacy Practices) of Nebraska Orthopaedic Center P.C.’s Notice of Privacy Practices which are effective January 1, 2022.

I understand that the Notice describes the uses and disclosures of my protected health information and informs me of my rights with respect to my protected health information.
Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient Signature*

Clear
***For Office Use Only****

Patient ID:_____________

Consent to Release Medical & Billing Information to Individuals /Family Members
The Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended, allows your healthcare provider or staff of Nebraska Orthopaedic Center (Practice) to discuss your medical or billing information with members of your family or other individuals involved in your medical care upon your approval, or when given the opportunity, you do not object, or when your healthcare provider reasonably infers from the circumstances, based on his/her professional judgment, that you do not object to such disclosure. To assist our Practice in determining your desires with respect to such disclosures, we ask that you complete this form. You may revoke or modify this consent at any time by submitting a revised form.

I AUTHORIZE Practice to disclose, to the following individuals, medical care and billing information, whether in person, over the phone or in writing, directly relevant to such individual’s involvement with my medical care or payment related to my medical care; provided, however, in the event I am incapacitated or there is an emergency situation, my healthcare provider may disclose my medical and billing information, whether in person, over the phone or in writing, that is directly relevant to those involved in my medical care, even though their name does not appear below, if the healthcare provider, based on his/her professional judgment, determines the disclosure is in my best interests.
Do you have any individuals you would like to disclose medical care and/or billing information?*

YesNo
*
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Signature*

Clear
Date*

MonthDayYear
Date
*** For Office Use Only***

Patient ID____________
Should be Empty:

	Helped	No Help	Temporary Relief	Not Tried
Ice
Heat
Rest/Activity Modification
Ant-Inflammatory Medications(s)
Pain Medication(s)
Chiropractor Care
Therapy
Home Exercise Program
Injections
Bracing
Changing Positions
Massage
Over the Counter Topical Creams
Tylenol

	Yes or NO	Body Part, right or left	Year	Physician and/or Facility
Abdominal Surgery
Arthroscopy
Arthroscopy
Fracture
Fracture
Heart Surgery/ Procedure
Heart Surgery/ Procedure
Joint Replacement
Joint Replacement
Spine Surgery
Vascular/ Vein/ Artery
Other
Other

Patient Paperwork for Satellite Clinics

Patient Information

Patient Medical Insurance Information

Responsible Party (if patient is a minor)

Patient Information

Location of the Problem

Injury History

Pain History

Treatment/Testing

Medical Questions

Family History

Social History

Medications

Allergies

Authorization to Release Information, Consent to Treatment & Assignment of Benefits

Receipt of Notice of Privacy Practices

Consent to Release Medical & Billing Information to Individuals /Family Members