• Patient Paperwork for Satellite Clinics

    If your appointment is at our Main Lincoln Offices, you’ll receive a text message or email to complete your paperwork.

  • Patient Information

  • Format: (000) 000-0000.
  • Primary Phone is:*
  • Format: (000) 000-0000.
  • Secondary Phone is:*
  • Language*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Were you referred to Nebraska Orthopaedic Center?*
  • By whom?*

  • Patient Medical Insurance Information

  • Do you have medical insurance?*
  • Is the policy holder's address the same as the patient?*
  • Do you have secondary insurance?*
  • Is the policy holder's address the same as the patient?*

  • Responsible Party (if patient is a minor)

  • Is this address the same as the patient?*
  • Format: (000) 000-0000.
  • Primary Phone is:*
  • Format: (000) 000-0000.
  • Secondary Phone is:*

  • Patient Information

  • Language*

  • Location of the Problem

  • Please indicate the location of your primary complaint: Side of Body:*
  • Location of the symptoms*
  • Dominant Hand*

  • Injury History

  • Is what we are seeing you for today due to an injury?*
  • Date of Injury*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Where did the injury occur?*
  • What sport were you playing?*

  • Pain History

  •
  • Does the pain radiate?*
  • How would you describe the symptoms?*
  • How often are the symptoms present?*
  • Is the problem getting better or worse?*
  • Do you have any other additional complaints?*
  • Do you experience any numbness of tingling?*
  • Where is the numbness or tingling located?*
  • What makes the symptoms better?*

  • Treatment/Testing

    Please indicate any prior tests for this problem
  • Did you have emergency room treatment?*
  • Have you had an MRI (Magnetic Resonance Imaging)?*
  • Date of MRI (Magnetic Resonance Imaging)?*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Have you had an x-ray?*
  • Date of x-ray?*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Have you had an CT (Computed Tomography) Scan?*
  • Date of CT (Computed Tomography) Scan?*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Have you had a Dexa?*
  • Have you had a Bone Scan?*
  • Have you had an Ultrasound?*
  • Have you had a Nerve Test (EMG/NCS)?*
  • Have you been seen by another provider for this problem?*
  • Have you received any treatment for this problem (ie. medication, therapy, injections, etc.)?*
  • Please indicate if you have had any of the following treatment (on your own or directed by a Provider) and if it helped or not:
    Rows
  • Have you ever had surgery on this body part?*

  • Type of surgery:*Date of surgery:   Pick a Date   Name of Surgeon:         

  • Medical Questions

  • Mark all that currently apply:*
  • Is the patient diabetic?*
  • Any previous complications?*

  • Have you or anyone in your family ever had a reaction to Anesthetic (General or Local)? Please select below.

  • Causing Malignant Hyperthermia (High Fever)?*
  • Relationship*
  • Have you ever had a surgical procedure?*
  • Please be specific as to the type of surgery, body part, right or left, year and Physician. *
    Rows

  • Family History

  • Have any direct relatives had any of the following disorders?*
    Rows

  • Social History

  • Do you smoke tobacco?*
  • How many packs a day?*
  • Do you drink alcohol?*
  • How often?*
  • Recreational Drug Use*
  • Do you have any work restrictions? (Lifting, prolonged sitting, etc.)*
  • Do you participate in sports?*

  • Medications

  • Do you currently take any medications? Including prescribed or over-the-counter.*
  • Please list ALL medications OR upload a file. If you upload a file please type, "Upload" in Medication box. *
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  • Allergies

  • Do you have an allergy to Latex?*
  • Do you have any allergies?*
  • Please list ALL allergies with severity and reaction. *
  • Please select if you have any of the following current medical conditions:*
  • Date Signed*
     / /
    2 digit month, 2 digit day, 4 digit year
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  • Browse Files
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  • Authorization to Release Information, Consent to Treatment & Assignment of Benefits

  • ***For Office Use Only***

    Patient Account Number:__________

  • I certify that the information that I have reported with regards to my insurance coverage is correct.

     I hereby authorize NEBRASKA ORTHOPAEDIC CENTER, P.C. to file claims and release any medical information necessary to process these claims. I also authorize payments to be made directly to NEBRASKA ORTHOPAEDIC CENTER, P.C. for the services provided to me (or the above-named patient), and authorize NEBRASKA ORTHOPAEDIC CENTER, P.C. to render appropriate treatment/procedures relating to the diagnosis. 

    I understand that I am financially responsible to NEBRASKA ORTHOPAEDIC CENTER, P.C. for the services provided to me or my dependent. I agree to pay the full amount of all charges incurred by the above-named patient that are not covered by my insurance carrier. I also agree to pay the cost of collection and/or court costs and reasonable fees should this be required.

    I understand and agree that any cellular or land line phone numbers and email addresses provided by myself to this office and to any of our services providers, including but not limited to, third party debt collectors, now and in the future, may be used as a means to contact me for any reason, including but not limited to, billing and collecting payment, and that this office and our service providers may leave messages for me manually and by using automatic systems such as by artificial or prerecorded voice. I also agree that this office and any service providers may contact me by sending text messages and emails to any phone number or email address I provide to this office or service providers, and I consent to receive such text messages and emails which may identify the name of this office or service provider sending the communication, and which may disclose the nature of the communications. In the future, should I acquire a new or different cellular, landline or email address, I agree that this consent would stay effective.

    I agree that Nebraska Orthopaedic Center, P.C. may request and use my prescription medication history from other healthcare providers or third-party pharmacy benefit payers for treatment purposes.

     

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • I hereby authorize Nebraska Orthopaedic Center, PC to appeal all claims for charges I will incur as a patient of this practice.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Receipt of Notice of Privacy Practices

  • I was given the opportunity to receive a copy (Nebraska Orthopaedic Center Notice of Privacy Practices) of Nebraska Orthopaedic Center P.C.’s Notice of Privacy Practices which are effective December 13, 2024.

     

    I understand that the Notice describes the uses and disclosures of my protected health information and informs me of my rights with respect to my protected health information.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • ***For Office Use Only**** 

    Patient ID:_____________

  • Consent to Release Medical & Billing Information to Individuals /Family Members

  • The Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended, allows your healthcare provider or staff of Nebraska Orthopaedic Center (Practice) to discuss your medical or billing information with members of your family or other individuals involved in your medical care upon your approval, or when given the opportunity, you do not object, or when your healthcare provider reasonably infers from the circumstances, based on his/her professional judgment, that you do not object to such disclosure. To assist our Practice in determining your desires with respect to such disclosures, we ask that you complete this form. You may revoke or modify this consent at any time by submitting a revised form.

     

    I AUTHORIZE Practice to disclose, to the following individuals, medical care and billing information, whether in person, over the phone or in writing, directly relevant to such individual’s involvement with my medical care or payment related to my medical care; provided, however, in the event I am incapacitated or there is an emergency situation, my healthcare provider may disclose my medical and billing information, whether in person, over the phone or in writing, that is directly relevant to those involved in my medical care, even though their name does not appear below, if the healthcare provider, based on his/her professional judgment, determines the disclosure is in my best interests.

  • Do you have any individuals you would like to disclose medical care and/or billing information?*
  • *
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • *** For Office Use Only***

    Patient ID____________

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