Ortho Rehab and Specialty Centers Patient Packet

Patient Packet

Ortho Rehab and Specialty Centers
Patient Information
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
2nd Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Sex
Social Security #
Occupation
type student or "n/a" if not applicable
Patient's Employers Name
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information
Emergency Contact Name

First NameLast Name
Emergency Contact's Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party Information

If you are someone other than patient
Are you the responsible party for the patient?
Relation to patient
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security #
Sex
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Occupation
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Consent for Care & Treatment
I, the undersigned, do hereby agree and give my consent for OR&SC to furnish medical care and treatment to the person's name listed below, and that it is considered necessary and proper in diagnosis or treating his/her physical and mental condition.
Patient's Name

First NameLast Name
Patient/Guardian/Responsible Party
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Benefit Assignment/Release of Information
I hereby assign all medical benefits to include major benefits to which I am entitled,
including Medicare, private insurance, and third-party payers to OR&SC. A photocopy of this assignment is to be considered as valid as the original. I hereby authorize said
assignee to release all information necessary, including medical records, to secure
payment
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature

Financial Policy Statement
We bill your insurance carrier solely as a courtesy to you. You are responsible for the entire bill when the services are rendered. We require that arrangements for payment of your estimated share be made today. If your insurance carrier does not remit payment within 60 days, the balance will be due in full. In the event that your insurance company requests a refund of payments made, you will be responsible for the amount of money refunded to your insurance company. In the event your company establishes an internal usual and customary fee schedule, you will be responsible for the difference remaining.

If any payment is made directly to you for services billed by us, you recognize an obligation to promptly submit the same to Orthopedic Rehabilitation and Specialty Center.

The above may not apply to those patients that are considered Worker’s Compensation. However, be advised if you claim Worker’s Compensation benefits and are subsequently denied such benefits, you may be held responsible for the total amount of charges for services rendered to you.

When you pay by check, you expressly authorize Orthopedic Rehabilitation and Specialty Center, if your check is dishonored or returned for any reason, to electronically debit your account for the amount of the check plus a processing fee of up to the state maximum legal limit (plus any applicable sales tax). Please note: the above language authorizes an electronic debit to your account for the state-allowed recovery fee. In accordance with the rules of the National Automated Clearing House Association, you may call (888) 235-4635 to revoke the authorization for the electronic transaction. This does not, however, mean that OR&SC cannot collect a returned check fee by the other methods.

I understand and agree that if I fail to make any of the payments for which I am
responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees.

Information Privacy: OR&SC will use and disclose your personal health information to treat you, to receive payment for the care we provide, and for other health care
operations. Health care operations generally include those activities we perform to
improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY
PRACTICES to help you better understand our policies in regard to your personal health information. The terms of the notice may change with time and we will always post the current notice at our facilities with copies for distribution. The undersigned acknowledges receipt of this information.

I UNDERSTAND MY RESPONSIBILITY FOR THE PAYMENT OF MY ACCOUNT.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

HIPAA NOTICE OF PRIVACY PRACTICES

This notice describes how medical/protected health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Summary:
By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notice describes how your medical information may be used and disclosed by us. It also tells you how you can obtain access to this information.

As a patient, you have the following rights:
1. The right to inspect and copy your information;
2. The right to request corrections to your information;
3. The right to request that your information be restricted;
4. The right to request confidential communications;
5. The right to a report of disclosures of your information; and
6. The right to a paper copy of this Notice.

We want to assure you that your medical/protected health information is secure with us. This Notice contains information about how we will insure that your information remains private.

If you have any questions about this Notice you may contact front office personnel at Phone Number: (501) 975-4040
Acknowledgment of Notice of Privacy Practices

“I hereby acknowledge that I have received a copy of the practice’s NOTICE OF
PRIVACY PRACTICES. I understand that if I have questions or complaints regarding
my privacy rights that I may contact the person listed above. I further understand that the practice will offer me updates to this NOTICE OF PRIVACY PRACTICES should it be amended, modified or changed in any way.
Patient or Representative Name

First NameLast Name
Patient or Representative Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If patient was unable to sign please specify why:
If patient refuses to sign please specify that they refused to sign
Should be Empty:

Rows	Yes	No
Chiropractor
EMG/NCV
Massage Therapy
Myelogram
Occupational Therapy
Physical Therapy
Emergency Room Care
CT Scan
General Practitioner
MRI
Neurologist
Orthopedist
Podietrist
X-Rays

Rows	Yes	No
Asthma, Bronchitis, or Emphysema
Shortness of Breath/ Chest Pain
Coronary Heart Disease or Angina
Do you have a Pacemaker?
High Blood Pressure
Heart Attack or Surgery
Stroke/TIA
Congestive Heart Disease
Blood Clot/Emboli
Epilepsy/Seizures
Thyroid Disease or Goiter
Anemia
Infectious Diseases
Diabetes
Cancer or Chemotherapy/Radiation
Arthritis
Osteoporosis
Gout
Sleeping Problems/Difficulties
Emotional/Psychological Problems

Rows	Yes	No
Severe or Frequent Headaches
Vision or Hearing Difficulties
Numbness or Tingling
Dizziness or Fainting
Bowel or Bladder Problems
Weakness
Weight Loss/Energy Loss
Hernia
Varicose Veins
Allergies
Any Pins or Metal Implants
Joint Replacement Surgery
Neck Injury/Surgery
Shoulder Injury/Surgery
Elbow/Hand Injury/Surgery
Back Injury/Surgery
Knee Injury/Surgery
Leg/Ankle/Foot Injury/Surgery
Are You Pregnant?
Do You use Tobacco?

Patient Packet

Patient Information

Emergency Contact Information

Responsible Party Information

Patient Medical History

Consent for Care & Treatment

Benefit Assignment/Release of Information

Financial Policy Statement

HIPAA NOTICE OF PRIVACY PRACTICES