Treating the complicated orthopaedic patient: Four cases ...
patient information sheet dark logo - Midwest...
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MIDWEST ORTHOPAEDIC CONSULTANTS Please complete this entire form, and present your insurance cards for billing purposes. PATIENT INFORMATION SHEET Pharmacy Name: ____________________________ Patient Name: ______________________________________ Pharmacy Location: __________________________ Last First MI_ Address: __________________________________________ Primary Care Physician: _______________________ Last First City, State, Zip: ____________________________________ Office Location: ______________________________ Sex: ______ Birth Date: ________________ Age: _______ Referring Physician: __________________________ Last First Social Security #: __________________________________ Office Location: ______________________________ Home Phone: (______) _______________________________ ________________________________________________ Cell Phone: (______) _______________________________ WORK-COMP Work Phone: (_____) _________________________ _____ Adjuster/RN Name: ________________________________ Email Address: ___________________________ _________ Insurance Company: _______________________________ Emergency Contact Contact Phone: ____________________________________ Name & Phone: _____________________________________ Is your visit due to a work related incident? Yes No If you answered yes to the questions above, please provide the date, and a brief description of the accident and your injury: ____________________________________________ ____________________________________________ ____________________________________________ ________________________________________________________________________________________________ PRIMARY INSURANCE CARRIER: SECONDARY INSURANCE CARRIER: Ins. Co. Name: ________________________________________________ Ins. Co. Name: _________________________________________ (if PPO or HMO please identify Plan) _____________________________ (if PPO or HMO please identify Plan) ______________________ Policy Holder Information: Policy Holder Information: Name: ________________________________________________________ Name: ________________________________________________ Last First MI Last First MI Policy Holder Sex: M □F Birth Date: ___________________________ Policy Holder Sex: □ M □F Birth Date: __________________ Policy Holder Social Security # :____________________________________ Policy Holder Social Security # :____________________________ Policy Holder relationship to patient: □ Self □ Spouse □ Parent Policy Holder relationship to patient: □ Self □ Spouse □ Parent Insurance ID Number: ____________________________________________ Insurance ID Number: ___________________________________ Group Number: _________________________________________________ Group Number: ________________________________________ Employer:______________________________________________________ Employer: ____________________________________________ (of Ins Policy Holder) (of Ins Policy Holder) Address: _______________________________________________________ Address: ______________________________________________ City, State, Zip: _________________________________________________ City, State, Zip: _________________________________________ Phone: (______) ________________________________________________ Phone: (_____) _________________________________________ ________________________________________________________________________________________________ I authorize the release of all medical information necessary to process my insurance claim. I assign all medical and/or surgical benefits including major medical benefits to which I am entitled to Midwest Orthopaedic Consultants. I understand that regardless of my insurance, I am financially responsible for the fees for services rendered and all collection and attorney fees if applicable. A photocopy of this assignment is considered as valid as the original. This assignment will remain in effect until revoked by me in writing. If the balance is not paid at the time of service, for whatever reason, it is agreed that our office is extending credit to you as a courtesy. If credit is extended, you authorize our office and/or our agents to access your consumer credit report. Patient Signature: (Parent/Guardian) ___________________________________________________________ Date: _____________________________________
Transcript of patient information sheet dark logo - Midwest...
MIDWESTORTHOPAEDICCONSULTANTS Pleasecompletethisentireform,andpresentyourinsurancecardsforbillingpurposes.PATIENTINFORMATIONSHEET PharmacyName:____________________________
PatientName:______________________________________ PharmacyLocation:__________________________LastFirstMI_
Address:__________________________________________ PrimaryCarePhysician:_______________________ LastFirst
City,State,Zip:____________________________________ OfficeLocation:______________________________Sex:______BirthDate:________________Age:_______ ReferringPhysician:__________________________ LastFirst
SocialSecurity#:__________________________________ OfficeLocation:______________________________
HomePhone: (______)_______________________________ ________________________________________________CellPhone: (______)_______________________________ WORK-COMP WorkPhone: (_____)______________________________ Adjuster/RNName:________________________________EmailAddress:____________________________________ InsuranceCompany:_______________________________EmergencyContact ContactPhone:____________________________________Name&Phone:_____________________________________ Isyourvisitduetoaworkrelatedincident?�Yes�No Ifyouansweredyestothequestionsabove,pleaseprovidethedate, andabriefdescriptionoftheaccidentandyourinjury: ____________________________________________ ____________________________________________ ____________________________________________________________________________________________________________________________________________PRIMARYINSURANCECARRIER: SECONDARYINSURANCECARRIER:
Ins.Co.Name:________________________________________________ Ins.Co.Name:_________________________________________ (ifPPOorHMOpleaseidentifyPlan)_____________________________ (ifPPOorHMOpleaseidentifyPlan)______________________PolicyHolderInformation: PolicyHolderInformation:Name:________________________________________________________ Name:________________________________________________ LastFirstMI LastFirstMIPolicyHolderSex:M□FBirthDate:___________________________ PolicyHolderSex:□M□FBirthDate:__________________PolicyHolderSocialSecurity#:____________________________________ PolicyHolderSocialSecurity#:____________________________PolicyHolderrelationshiptopatient:□Self□Spouse□Parent PolicyHolderrelationshiptopatient:□Self□Spouse□ParentInsuranceIDNumber:____________________________________________ InsuranceIDNumber:___________________________________GroupNumber:_________________________________________________ GroupNumber:________________________________________Employer:______________________________________________________ Employer:____________________________________________(ofInsPolicyHolder) (ofInsPolicyHolder)Address:_______________________________________________________ Address:______________________________________________
City,State,Zip:_________________________________________________ City,State,Zip:_________________________________________
Phone:(______)________________________________________________ Phone:(_____)_________________________________________
________________________________________________________________________________________________Iauthorizethereleaseofallmedicalinformationnecessarytoprocessmyinsuranceclaim.Iassignallmedicaland/orsurgicalbenefitsincludingmajormedicalbenefitstowhichIamentitledtoMidwestOrthopaedicConsultants.Iunderstandthatregardlessofmyinsurance,Iamfinanciallyresponsibleforthefeesforservicesrenderedandallcollectionandattorneyfeesifapplicable.Aphotocopyofthisassignmentisconsideredasvalidastheoriginal.Thisassignmentwillremainineffectuntilrevokedbymeinwriting.Ifthebalanceisnotpaidatthetimeofservice,forwhateverreason,itisagreedthatourofficeisextendingcredittoyouasacourtesy.Ifcreditisextended,youauthorizeourofficeand/orouragentstoaccessyourconsumercreditreport.
PatientSignature:(Parent/Guardian)___________________________________________________________Date:_____________________________________
