Type of surgery:blanks*Date of surgery: Date Name of Surgeon: Type a label
Have you or anyone in your family ever had a reaction to Anesthetic (General or Local)? Please select below.
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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.
I hereby authorize Nebraska Orthopaedic Center, PC to appeal all claims for charges I will incur as a patient of this practice.
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.
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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.
*** For Office Use Only***