Patient Information

Patient Information

The person seeing the physician
Orthopedic Associates Doctor *
Name *

First Name Middle Name Last Name
Preferred Name
Date of Birth *

Month Day Year
Date
Date of Appointment *

Month Day Year
Date
Time of Appointment *

: Hour Minutes AM/PM Option
Marital Status *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone *

Area Code Phone Number
Secondary Phone

Area Code Phone Number
Email Address *
example@example.com
Preferred method of contact *
Gender *
Social Security Number
HIPAA Secure, last 4 digits is okay
Referring Physician
Primary Care Physician
Government regulations require us to ask the following:
Language
Race
Ethnicity
I decline to answer
Guarantor Information

The responsible party
Same as patient
Guarantor Name *

First Name Middle Name Last Name
Guarantor Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Guarantor Primary Phone *

Area Code Phone Number
Guarantor Gender *
Guarantor Social Security Number
HIPAA Secure
Guarantor Date of Birth *

Month Day Year
Date
Additional Information
How did you learn about our office?
Are you employed?
Employer *
Are you a student?
School *
Insurance Information

Please bring your insurance card with you
I would like to self pay (no insurance)
Primary Carrier Name *
Carrier Phone Number (found on back of card) *

Area Code Phone Number
Insured Relationship to Patient *

Self Guarantor Spouse Child
Insured ID/Policy Number *
Group Number/Plan Name *
Same as patient
Primary Policy Holder Name *
Policy Holder Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Policy Holder Date of Birth *

Month Day Year
Date
Policy Holder Phone Number *

Area Code Phone Number
Policy Holder Gender *
I would like to add secondary insurance
Secondary Carrier Name *
Secondary Carrier Phone Number (found on back of card) *

Area Code Phone Number
Secondary Insured Relationship to Patient *

Self Guarantor Spouse Child
Secondary Insured ID/Policy Number *
Secondary Group Number/Plan Name *
Same as patient
Secondary Policy Holder Name *
Secondary Policy Holder Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Secondary Policy Holder Date of Birth *

Month Day Year
Date
Secondary Policy Holder Phone Number *

Area Code Phone Number
Secondary Policy Holder Gender *
Emergency Contact
Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
Pharmacy
Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Motor Vehicle Accident
Is the problem you are being seen for related to a motor vehicle accident?
Date of Accident *

Month Day Year
Date
State where accident occurred *
Work Related Injury
Is the problem you are being seen for due to a work related injury?
Have you notified your employer of the injury?
Do you know if your employer has filed it to their insurance carrier?
What is/was the name of your employer at the time of the accident? *
What was the date of injury? *

Month Day Year
Date
Briefly describe how this work related accident occurred *
If this is a work related injury but you prefer it not to be filed to your workers' compensation carrier, please note: It is your choice to ask us to file under your private insurance; however, we will be unable to go back and file to your work insurance. If that is your choice, please indicate and sign the acknowledgement below.
I prefer that you file my private insurance and not my worker's compensation insurance.
Signature and acknowledgement *

Clear
Third Party Billing
Are you expecting someone other than your insurance carrier (or you if self-pay) to pay this bill?
Who? *
Why? *
Notice of Privacy Practices
I have received a copy of this office's Notice of Privacy Practices. I hereby authorize the following persons to receive medical information regarding my care.
Acknowledgment Signature/Legal Guardian Signature *

Clear
Should be Empty:

Patient Information

Guarantor Information

Additional Information

Insurance Information

Emergency Contact

Pharmacy

Motor Vehicle Accident

Work Related Injury

Third Party Billing