Patient Information
Academy Orthopaedic Clinic
Please complete all that applies to you and then print this entire form and bring it with you to your appointment. This will expedite your visit with your provider. Thank You!!
DATE Name
Address
Telephone Number , Home Business
Age Date of Birth Sex Social Security No
If Child, Father's Name Mother's Name
Employer's Name
Spouse's Name
Spouse's Employer Name Occupation
PERSON RESPONSIBLE FOR PAYMENT
Self Spouse Other
Name
City state Zip
Telephone No: Horne Business
FOR EMERGENCY CONTACT (Friend or relative Not Living with You)
Name Relationship
Address Telephone
Urgent Care Center Emergency Room of Presbyterian / Kaseman Presbyterian / St Joseph Downtown /St. Joseph West Mesa
St. Joseph Northeast Heights / UNM Urgent Care / UNM Emergency Room
Attorney / Employer / School Coach / Trainer Friend / relative
Telephone Book / Yellow Pages Insurance Plan Booklet
CHIEF COMPLAINT:
1. Major Orthopaedic Problem:
2. Secondary Problem:
( PLEASE NOTE THAT WE WILL BE ABLE TO SEE ONE MAJOR ORTHOPAEDIC PROBLEM PER VISIT, POSSIBLY A SECONDARY PROBLEM, IF TIME IS AVAILABLE)
PRIMARY INSURANCE
Name of your Insurance Company
I.D. Number , Policy or Group Number
Name of insured
SECONDARY INSURANCE
Please remember that, your health insurance is a contract between you and the insurance company. You are ultimately responsible for the timely payment of your account.
PLEASE READ THE FOLLOWING CAREFULLY, AND SIGN BELOW:
PAYMENT FOR CHARGES IS DUE AT TIME OF SERVICE:
If surgery is indicated, the patient is responsible for furnishing insurance information prior to surgery. For your convenience, our office will be happy to file your primary insurance for you. I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance on my account for any professional services rendered. I have read the financial policy of Academy Orthopaedic Clinic and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or the above information.
Signature of Patient or Responsible Party Date
INSURANCE AUTHORIZATION AND AGREEMENT:
I hereby authorize Academy Orthopaedic Clinic to furnish information to insurance carriers concerning my illness and treatment, and I hereby assign to the physician all payments or medical services rendered to myself or my dependents, that are not paid for at the time of service. I understand that I am responsible for any amount not covered by insurance. A photocopy of this assignment is to be considered as valid as an original. A one-time service fee of $10.00 will be added to my account balance if it is 60 + days old and prior payment arrangements have not been made and adhered to.
Signature of Insured or Responsible Party Date
Important Information, PLEASE READ CAREFULLY.
1. Payment is due when services are rendered unless otherwise arranged with office manager. Interest at 1.5% per month on the unpaid balance shall be added after thirty (30) days unless waived by your provider.
2. At the time of service you will be given a receipt form for you to forward to your insurance company unless your plan has other provisions. We cannot accept responsibility for collection of your claim and any balance is YOUR responsibility. If full payment is not received within thirty (30) days from the insurance company or third party payer, then payment in full shall be made by patient or responsible party directly to Academy Orthopaedic Clinic.
3. 1 consent to the administration of such medications and treatment considered necessary to advisable by my provider.
4. I agree to all payment terms stated above and acknowledge that I am personally responsible for payment of all charges.
5. 1 authorize Academy Orthopaedic Clinic, to release any information necessary to process this claim or payment of my bill. I also authorize payment of medical benefits be made directly to Academy Orthopaedic Clinic.
6. I further acknowledge and represent that, based on my present information, there is no third party liability. [Check here if there is no third party liability ]
7. 1 have not met my Medicare deductible. [Check here if you have met your Medicare deductible ]
8. I understand that it is mandatory to notify the healthcare provider of any other party who may be responsible for paying for my treatment (Section 1128B of the Social Security Act and 31 U.S.C. 3801-3812 provides penalties for withholding this information). Regulations pertaining to Medicare assignment of benefits also apply.
Patient or responsible party (you have to sign this form when you come to our office before this form is official)
Signature: Date
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