Nebraska Orthopaedic Center | Patient Information

Patient Information
Patient Name *

First Name Middle Name Last Name
Patient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient Date of Birth *

Month Day Year
Patient Age *
Example: 23
Patient Gender *
Martial Status *
Primary Phone *
Please enter a valid phone number.
Primary Phone is: *

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

Home Mobile Work Other
Social Security Number
E-Mail Address *
Enter "None" if no email.
Race *
Ethnicity *
Language *

English Spanish Other
Employment Status *
Employer Name *
Occupation *
Employer Address *

Street Address

City State / Province

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

First Name Last Name
Spouse's Phone *
Please enter a valid phone number.
Spouse's Employment Status *
Employer Name *
Were you referred to Nebraska Orthopaedic Center? *

Yes No
By whom? *

Primary Care Provider Referring Provider Family Member Friend
Referring Provider Name *
Primary Care Provider *
Ie. Physician/PA-C/APRN First and Last Name
Patient Medical Insurance Information
Do you have medical insurance? *

Yes No
Primary Insurance *
Policy Holder *
Policy Holder's Name *

First Name Last Name
Policy Holder Date of Birth *

Month Day Year
Is the policy holder's address the same as the patient? *

Yes No
Policy Holder Address *

Street Address

City State / Province

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

Yes No
Secondary Insurance *
Policy Holder *
Policy Holder's Name *

First Name Last Name
Policy Holder Date of Birth *

Month Day Year
Is the policy holder's address the same as the patient? *

Yes No
Policy Holder Address *

Street Address

City State / 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 Name Middle Name Last Name
Is this address the same as the patient? *

Yes No
Address *

Street Address

Street Address Line 2

City State / Province

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

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

Home Mobile Work Other
Employer *
Relationship *
Emergency Contact
Emergency Contact Name *

First Name Last Name
Relationship *
Primary Phone *
Please enter a valid phone number.
Patient Health History
Height *
Weight in pounds *
Dominant Hand *

Left Right
Have you had any fractures, surgery or hospitalizations? *

Yes No

Have you ever had (Please check all that apply and explain below: *

Anemia Diabetes Insulin Pump Intestinal/ Bowel Problems Phlebitis Arthritis DVT/ Blood Clots Kidney Problems Polio Asthma Epilepsy Liver Disease Psychological Problems Birth Defects Gallbladder Problems Lung Problems Pulmonary Embolism Black Lung Disease Gout MRSA/ Staph Infection Rheumatic Fever Bladder Problems Heart Trouble Neurologic Disorder Sexually Transmitted Disease Bleeding Tendency Hepatitis Neuropathy Stroke/ TIA Blood Transfusion High Blood Pressure Osteoporosis Thyroid Problems Cancer High Cholesterol Pacemaker Tuberculosis Cortisone Drug HIV/ AIDS Peripheral Vascular Disease Ulcer (Type ) Defibrillator None of these Apply
Any explanation of the above checked items
Do you smoke? *

Yes No Former Smoker
How many packs a day? *

0-1 pack/day 1-2 packs/day 2+ packs/day
Year Started ? *
Year Quit? *
Alcohol Use *

Yes No
Please indicate amount and frequency *
Recreational Drug Use *

Yes No
What and how often? *
Please list any additional information you feel would be important to your treatment.
Do you currently take any medications? Including prescribed or over-the-counter. *

Yes No
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.

Cancel of
Pharmacy Name *
Example: CVS
Pharmacy Address *

Street Address- Example: 14th & Superior

Street Address Line 2

City State / Province

Postal / Zip Code
Do you take Aspirin daily? *

Yes No
What is the mg of the Aspirin? *

81 mg 325 mg
Do you take a blood thinning medication? ex. Coumadin *

Yes No
What name of blood thinning medication are you on? *
Do you have any medication allergies? *

Yes No
Please list ALL medication allergies and reaction. *
Do you have any non-medication allergies? *

Yes No
Please list ALL non-medication allergies and reaction. *
Do you have an allergy to Latex? *

Yes No
Please describe your reaction: *
Any metal allergy? Including jewelry *

Yes No
Please list type of metal: *
Example: Nickel
Please explain reaction: *
Example: Rash
Have you or anyone in your family ever had a reaction to Anesthetic (General or Local)? Please select below.
Causing Malignant Hyperthermia (High Fever)? *

Yes No
Relationship *

Self Mother Father Sibling Child/Children
Blood Pressure Problems due to anesthetic? *

Yes No
Relationship *

Self Mother Father Sibling Child/Children
Hepatitis due to Anesthetic? *

Yes No
Relationship *

Self Mother Father Sibling Child/Children

Do you know any blood relative (Mother, Father, Sibling, or Child) who has or had the following disease/illness? Please select yes or no and relationship. *

	Yes or No	Mother	Father	Sibling	Child
Alzheimer's
Arthritis
Bleeding Tendency
Cancer
Diabetes
Gout
Heart Disease
Kidney Disease
Osteoporosis
Stroke
Sudden Death

Please answer all questions below regarding today's problem only.
What body part(s) are we seeing you for today? *
Which side of this body part? *

Left Right Not Applicable
Is what we are seeing you for today due to an injury? *

Yes No
Date of Injury *

Month Day Year
Date
Where did the injury occur? *

Home Work Auto/Liability Other
How did the injury occur? *
When did you first notice symptoms? *
What are those symptoms? *
Did you have emergency room treatment? *

Yes No
What emergency room? *
Have you had an x-ray? *

Yes No
Where was your x-ray taken? *
Have you had an MRI (Magnetic Resonance Imaging)? *

Yes No
Where was your MRI taken? *
Have you had an CT (Computed Tomography) *

Yes No
Where was your CT taken? *
Have you had a Nerve Test (EMG/NCS)? *

Yes No
Where did you have a Nerve Test (EMG/NCS) at? *
Have you had any Physical Therapy? *

Yes No
Where did you have Physical Therapy at? *
Have you had any Cortisone Injections for the problem we are seeing for today? *

Yes No
Whom did you receive Cortisone Injections from? *
Review of Systems

Please check the following symptoms you have experienced on a regular basis or are being treated for by another provider.
General *

Fever Weight Change Hormonal Problems None Other
Cardiovascular *

Chest Pain Palpitations Fluid/Swelling in extremities Pacemakers None Other
Kidney/Bladder *

Painful urination Frequent urination Incontinence None Other
Respiratory *

Shortness of breath Sleep Apnea Wheezing None Other
Eyes *

Glasses/Contacts Cataracts Glaucoma None Other
Ears, Nose, Throat *

Difficulty Swallowing Ear Pain Seasonal allergies None Other
Gastrointestinal *

Heartburn Diarrhea/Constipation Abdominal pain Nausea/Vomiting None Other
Hematologic/Lymphatic *

Anemia Blood problems Clotting disorder Lymph problems None Other
Psychological *

Anxiety Depression Mood Swings None Other
Neurological *

Headaches Numbness Tingling Seizures Weakness None Other
Skin *

Rashes Lumps None Other
Patient Signature *

Clear
Date Signed *

Month Day Year
Date
Patient/Guardian Signature *

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

Cancel of
Insurance Card MUST add front and back

Cancel of

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

First Name Last 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

Month Day Year
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

Month Day Year
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 *

Month Day Year
Date
Patient Name *

First Name Last 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? *

Yes No
*
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Patient Signature *

Clear
Date *

Month Day Year
Date
*** For Office Use Only***

Patient ID____________
Please verify that you are human *
Should be Empty:

	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
Other
Other
Other

Patient Information

Patient Medical Insurance Information

Responsible Party (If Patient is a minor)

Emergency Contact

Patient Health History

Have you or anyone in your family ever had a reaction to Anesthetic (General or Local)? Please select below.

Please answer all questions below regarding today's problem only.

Review of Systems

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