Today’s Date: _____/_____/______
MM DD YYYY
Name: _________________________________ ______________________________ ________ ______________________________
Last First MI Nickname
DOB: _____/_____/________ Sex: M☐ F ☐ SSN: ______-____-_______ Email: _____________________@_____________. ______
MM DD YYYY
Vocational Status: Retired☐ Employed F/T☐ Employed P/T ☐ Unemployed☐ Student☐ DL#: _______________________
Marital Status: Married☐ Single☐ Separated☐ Spouse Name: ___________________________ __________________ ________
Divorced☐ Widowed☐ Spouse DOB: _______/_______/_______
Primary Language: ___________ For languages other than English, do you need an interpreter? _____
Home Phone: ______-______-__________ Work Phone: ______-______-__________ Mobile Phone: ______-______-__________
Physical Address: _________________________________________ Mailing Address: ____________________________________
City: ____________________State: ______Zip:________ City: ____________________State: ______Zip:________
Employer Name: _________________________________________ Phone: ______-______-__________
Spouse’s Employer Name: _________________________________________ Phone: ______-______-__________
Emergency Contact: Name: __________________________________________ Relationship: _________________________________
Home Phone #: ________-________-____________ Cell/Other Phone #: ________-________-____________
Insurance Information: PLEASE provide our office with a copy of your insurance card(s)/information. Check ALL that apply.
Medicare☐ Medicare Advantage Plan ☐_____________________ Worker’s Comp ☐___________________
Medicaid☐ TriCare☐ SSN of subscriber: _____-___-______ Blue Cross/Blue Shield ☐
If the Insured for PRIMARY coverage is someone other than the patient please identify here: Spouse ☐ Parent ☐
Primary Insured’s Name: _____________________________________________________ DOB: ______/_____/_____
If the Insured for SECONDARY coverage is someone other than the patient please identify here: Spouse ☐ Parent ☐
Secondary Insured’s Name: ___________________________________________________ DOB: _____/_____/_____
Medicaid Recipients ONLY:
If you have Medicaid coverage, who is listed as your Carolina Access Physician: ______________________________________________________________
County of issuance: ________________________
Primary Care Physician: ______________________________________________ Diabetic Care Physician: ________________________________________
Briefly describe the reason for your visit: ______________________________________________________________________________
Is your visit due to an accident?: Yes ☐ No ☐ If YES, what type? Auto ☐ Employment ☐ Other ☐ Date of Accident: ____/____/____
Have you had any surgeries related to this visit? Yes ☐ No ☐ If YES, when? ____/____/____
Have you been diagnosed with diabetes? Yes ☐ No ☐ If YES, date of diagnosis ____/____/____
Heart Problems ☐ Hepatitis C ☐ Hepatitis A or B ☐ Hypertension ☐ Alzheimer’s Disease ☐ HIV Positive ☐ Psychiatric Problems ☐ Vascular Disease ☐ Arthritis ☐ Alcoholism ☐
Stroke ☐ Obesity ☐ Pacemaker ☐ Seizure Disorder ☐ Kidney Disease ☐ Pulmonary Disease ☐ Hearing Loss ☐ Osteoporosis ☐ MRSA ☐ Vision Problems ☐ Currently Pregnant ☐ Parkinson Disease ☐
Have you had an orthotic/prosthetic device within the past 5 years? Yes ☐ No ☐ If yes, approximately when? _____/_____/_____
Insurance Assignment & Payment Policy (Conditions of contract(s) by and between O&P of Pinehurst and an insurance carrier may override office policies.)
Our office is pleased to accept insurance assignment for covered items only. As soon as coverage can be verified by the insurance carrier and the item(s) is/are delivered, our office will file the claim thereby assisting the patient with getting the claim paid.
Insurance should forward payment within 45 days of a claim being filed. If the insurance carrier takes longer than 60 days to pay, the patient/responsible party may be asked to make payment in full.
Our office cannot guarantee payment by any insurance carrier. We will make every attempt, at the beginning of service, to obtain verification of the policy coverage for services prescribed/requested and/or authorization if necessary.
In the event an insurance carrier reimburses the patient instead of O&P of Pinehurst for services rendered, the remaining balance becomes the patient’s or responsible party’s responsibility.
Any special financial arrangements must be made between the patient/responsible party and a qualifying representative of O&P of Pinehurst. All agreements must be signed by both parties.
Any costs associated with collection of payment from the patient is at the expense of the patient.
By signing below the patient/legally responsible person:
A. Certifies that he/she is authorized to furnish the requested information. Patient/legally responsible person understands that responsibility of payment lies with the patient/legally responsible person, not the insurance carrier.
B. Is in agreement with all stated policies herewithin.
C. Authorizes O&P of Pinehurst to file insurance claims on his/her behalf and accept assignment of benefits when applicable.
D. Authorizes the release of any information to the payer necessary to facilitate payment.
E. Permits a copy of this authorization to be used in place of the original and request payment of insurance benefits be made to the party accepting assignment of benefits.
F. Acknowledgement of receipt of the Notice of Privacy Practices; and
G. Acknowledge an understanding that the products and/or services provided to you by Orthotics & Prosthetics of Pinehurst are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g. honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards.
If patient is under 18 years of age, this form must be signed by a legally responsible adult who will be financially responsible.
Signature: _________________________________________________________________ Date: _____/_____/________
Signed by someone other than patient? Yes ☐ No ☐ If Yes, identify relationship? ___________________________
*Witnessing signature does not establish financial responsibility.