Patient Intake Form

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SECTION 1: PATIENT INFORMATION

PERSONAL INFORMATION

Title:

Name:

First

Middle

Last

DOB:

Sex:

Male
Female

Marital Status:

Preferred Language:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone:

Type:

Cell
Home
Work
Other:

Emergency Contact:

Relation to Patient:

Spouse
Child
Other

Contact Phone:

Type:

Cell
Home
Work
Other:

Is the patient also the guarantor?

If yes, skip to PHYSICIAN INFORMATION

Guarantor Name:

Relation to Patient:

Spouse
Child
Other

Guarantor Phone:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

PHYSICIAN INFORMATION

Referring Physician:

Referring Physician Phone:

Primary Care Physician:

Primary Care Physician Phone:

CONDITION INFORMATION

Are you diabetic?

If yes, provide the name and address of the physician treating your diabetes.

Physician Name:

Phone

Email which (if

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was your condition the result of an accident?

If no, skip to INSURANCE INFORMATION.

Was your injury work related?

If yes, provide employer at time of accident.

Employer Name:

Date of Injury:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Was your injury the result of an automobile accident?

If no, skip to INSURANCE INFORMATION.

Insurance Adjuster Name:

Phone:

Claim #:

SECTION 2: INSURANCE INFORMATION

Please be sure to bring your insurance cards and photo ID to your appointment

Primary Insurance:

Policy #:

Group #:

Subscriber Name (if different than patient):

Address:

Phone:

Secondary Insurance:

Policy #:

Group #:

Subscriber Name (if different than patient):

Address:

Phone:

I certify that the information provided by me is true, accurate and complete.

Name of Patient/Guarantor

Clear Signature

Date:

Patient Registration Signature Form

Patient Name:

I understand that some circumstances may require you to contact me regarding my care. By signing this form, I authorize Palmetto Orthotics and Prosthetics to contact me regarding appointments, treatment instructions, billing/account information or other matters specific to my care.

Please check which of the following modes of communication Palmetto Orthotics and Prosthetics may use to contact you

Voice Messages
Secured Emails/Texts#*
Unsecured Emails/Text Messages#**

Home #:

Work #:

Mobile #:

Email:

Revocation of authorization to contact me via email and/or text: I understand that I may revoke my consent for future communications via email and/or text at any time by advising Palmetto Orthotics and Prosthetics in writing. My revocation of authorization will not affect my ability to obtain future health care, nor will it cause the loss of any benefits to which I am otherwise entitled.

Authorization for disclosure of Protected Health Information (PHI): I authorize Palmetto Orthotics and Prosthetics to share information regarding my treatment, or payment for treatment, with the following individuals

Information to be shared with:

Spouse or partner
Other Individual

Name

I understand that payment of authorized Medicare, Medicaid, or private insurance benefits be made to Palmetto Orthotics and Prosthetics or any of its subsidiaries for any covered services furnished by Palmetto Orthotics and Prosthetics. I agree to pay Palmetto Orthotics and Prosthetics the deductible and/or coinsurance on my claim. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents, Campus/TRICARE and its agents, or any private insurance company any information needed to determine these benefits or the benefits payable for related services. Your signature below is also an acknowledgement that you have received or have been advised of the opportunity to review a copy of Palmetto Orthotics and Prosthetics Notice of Privacy Practices.

Signature of Patient or Responsible Party:

Clear Signature

Date:

Signature of Reprsentative (acknowledging receipt only):

Clear Signature

Date

Relationship to Patient:

Signature of Witness (if patient signed with a mark):

Clear Signature

Date

Printed Name of Witness

Why A Witness Is Required

Patient Refused to Sign for Receipt of the NPP
Patient is incapacitated
Other (Please explain)

Reason for Patient’s Inability/Refusal to Sign***:

#Text Communications: I understand that text message charges from my mobile phone provider may apply.

*Unless requested otherwise, emails and texts will be sent encrypted, excluding appointment reminders.

**I acknowledge that unsecured email/texts are not a secure medium for sending or receiving PHI. There is a possibility that my emails and text messages may be read or otherwise accessed by a third party in transit. Although Palmetto Orthotics and Prosthetics will make a reasonable effort to keep email and text communication confidential and secure, Palmetto Orthotics and Prosthetics cannot assure or guarantee the confidentiality of email/text communications.

***Palmetto Orthotics and Prosthetics made good faith efforts to obtain the above referenced individual’s written acknowledgement of receipt of the Notice of Privacy Practices.

SECTION 1: PATIENT INFORMATION

PERSONAL INFORMATION

PHYSICIAN INFORMATION

CONDITION INFORMATION

SECTION 2: INSURANCE INFORMATION

Patient Registration Signature Form

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