For Patients

Contact Us

SECTION 1: PATIENT INFORMATION

Personal Information

Title:

Mr

Ms

Mrs

Name:

DOB:

Sex:

Male

Female

Marital Status:

Preferred Language:

Address:

Primary Phone:

Type:

Cell

Home

Work

Other

Email:

Emergency Contact:

Relation to Patient:

Spouse

Child

Other

Contact Phone:

Type:

Cell

Home

Work

Other

Is the patient also the guarantor? (If yes, skip to PHYSICIAN INFORMATION)

Guarantor Name:

Relation to Patient:

Spouse

Child

Other

Guarantor Phone:

Address:

Physician Information

Referring Physician Phone:

Primary Care Physician:

Primary Care Physician Phone:

Condition Information

Are you diabetic? (If yes, provide the name and address of the physician treating your diabetes)

Physician Name:

Phone:

Address:

Have you received a similar service in the past 5 years?

Are you in hospice care?

Are you a resident of a skilled nursing facility (nursing home)?

Was your condition the result of an accident? (If no, skip to INSURANCE INFORMATION)

Was your injury work related? (If yes, provide employer at time of accident)

Employer Name:

Date of Injury:

Address:

Was your injury the result of an automobile accident? (If no, skip to INSURANCE INFORMATION)

Insurance Adjuster Name:

Phone:

Claim #:

SECTION 2: INSURANCE INFORMATION

Primary Insurance:

Policy #:

Group #:

Subscriber Name (if different than patient):

Address:

Phone:

Secondary Insurance:

Policy #

Group #:

Subscriber Name (if different than patient):

Address:

Phone:

I certify that the information provided by me is true, accurate and complete.

Yes

Name of Patient/Guarantor

Date:

Patient Registration Signature Form

New Field:

I understand that some circumstances may require you to contact me regarding my care. By signing this form, I authorize Palmetto Orthotics and Prosthetics to contact me regarding appointments, treatment instructions, billing/account information or other matters specific to my care.

Yes

Please check which of the following modes of communication Palmetto Orthotics and Prosthetics may use to contact you

Voice Messages

Secured Emails/Texts

Unsecured Emails/Text Messages

Home phone #:

Work phone #:

Mobile phone #:

Email:

Revocation of authorization to contact me via email and/or text: I understand that I may revoke my consent for future communications via email and/or text at any time by advising Palmetto Orthotics and Prosthetics in writing. My revocation of authorization will not affect my ability to obtain future health care, nor will it cause the loss of any benefits to which I am otherwise entitled.

Yes

Authorization for disclosure of Protected Health Information (PHI): I authorize Palmetto Orthotics and Prosthetics to share information regarding my treatment, or payment for treatment, with the following individuals

Yes

Information to be shared with:

Spouse or partner

Other individual

Name:

I understand that payment of authorized Medicare, Medicaid, or private insurance benefits be made to Palmetto Orthotics and Prosthetics or any of its subsidiaries for any covered services furnished by Palmetto Orthotics and Prosthetics. I agree to pay Palmetto Orthotics and Prosthetics the deductible and/or coinsurance on my claim. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents, Campus/TRICARE and its agents, or any private insurance company any information needed to determine these benefits or the benefits payable for related services. Your signature below is also an acknowledgement that you have received or have been advised of the opportunity to review a copy of Palmetto Orthotics and Prosthetics Notice of Privacy Practices.

Yes

Signature of Patient or Responsible Party:

Date:

Signature of Reprsentative (acknowledging receipt only):

Date:

Relationship to Patient:

Signature of Witness (if patient signed with a mark):

Date:

Printed Name of Witness

Select which apply

Patient Refused to Sign for Receipt of the NPP

Patient is incapacitated

Other (Please explain)

Other:

Reason for Patient’s Inability/Refusal to Sign:

#Text Communications: I understand that text message charges from my mobile phone provider may apply. *Unless requested otherwise, emails and texts will be sent encrypted, excluding appointment reminders. **I acknowledge that unsecured email/texts are not a secure medium for sending or receiving PHI. There is a possibility that my emails and text messages may be read or otherwise accessed by a third party in transit. Although Palmetto Orthotics and Prosthetics will make a reasonable effort to keep email and text communication confidential and secure, Palmetto Orthotics and Prosthetics cannot assure or guarantee the confidentiality of email/text communications. ***Palmetto Orthotics and Prosthetics made good faith efforts to obtain the above referenced individual’s written acknowledgement of receipt of the Notice of Privacy Practices.

Yes

Request an Appointment

If you have any questions or would like to schedule an appointment with one of our experts, please contact us

Patient intake form

Contact Us

FORMS FOR PATIENTS

Questions?

Want to schedule a call with one of our experts?

OUR SERVICES

CONTACT US

For Patients

Request an Appointment

If you have any questions or would like to schedule an appointment with one of our experts, please contact us

Patient intake form

Contact Us

FORMS FOR PATIENTS

Questions?

﻿Want to schedule a call with one of our experts?

Want to schedule a call with one of our experts?