ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA FAX (Revised March 11, 2012)
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1 ADVANCED ORTHOPAEDIC INSTITUTE 103 E. Third St Arlington, WA FAX (Revised March 11, 2012) PATIENT REGISTRATION FORM & FINANCIAL PAYMENT POLICY Patient Info: Please print Today s Date: Name DOB SSN Address Primary Phone wk/cell Alternate Phone wk/ cell Emergency Contact Relation Emergency Number Family/Primary Physician Referred by? Marital Status: Single Married Other Language: English Spanish Ethnicity: Hispanic or Latino Non Hispanic/Latino Decline Race: White/Caucasian African American Asian Other/Private American Indian/ Alaska Native Pacific Islander/Hawaiian Employer Work Phone Employer Address Is this injury job-related? Yes No Where did injury occur? ************************************************************************************* Guarantor Info: (person responsible for bill and/or primary person on insurance account) If info is same as above, mark here and go to Page 2: If different please complete mark here and complete below, then go to Page 2: Spouse: Parent: Name DOB SSN Address Primary Phone wk/cell Alternate Phone wk/ cell Employer Work Phone
2 INSURANCE INFO PRIMARY INSURANCE SECONDARY INSURANCE L&I Patients: Name of Worker s Compensation Insurance (CIRCLE ONE at right) D&LI (STATE CLAIM) SILI (SELF-INSURED CLAIM ) NAME n/a L&I Patients: Date of Injury n/a L&I Patients: Claim Number n/a Name of Insurance Company Subscriber s Name Subscriber s Employer Subscriber s Policy ID Number Subscriber s Group Number Subscriber s DOB & Sex: M or F Subscriber s Address & Phone if different from patient or guarantor Relation of Subscriber to Patient ***If you have a tertiary insurance, please let our office staff know ***If you have a co-pay, it MUST be paid at time of service. See office policies. This is a requirement of your insurance. ***Patients may be required to establish a payment plan with our office. Payment plans require a copy of a debit or credit card. This information (the form in its entirety) is true to the best of my knowledge. I authorize the physician and clinic to release any information to process insurance claims. I also authorize my insurance to be paid directly to the clinic. I understand that I am ultimately responsible for charges associated with medical services provided by this office and agree and guarantee to pay all bills within 30 days from the receipt of statement, unless other arrangements are made with this office. I further agree to pay any attorney s fees, court costs, and related collections fees incurred as relating to my account. All unpaid balances over 90 days will be sent to a collections agency and will be subjected to an interest rate set by the collection agency. PATIENT SIGNATURE DATE FOR MEDICARE BENEFICIARIES ONLY: PLEASE READ & SIGN I request payment of authorized Medicare benefits be made on my behalf for any services furnished to me by or in the office of Advanced Orthopaedic Institute. I authorize any holder of medical and other information about me to release to Medicare and its agents any information needed to determine these benefits or the benefits payable for related services. PATIENT SIGNATURE DATE
3 ADVANCED ORTHOPAEDIC INSTITUTE Office of JEFF CARTWRIGHT, M.D. 103 E. Third St. ARLINGTON, WA FAX OFFICE POLICIES (Revised June 27, 2013) 1. MEDICATION: For non-narcotic medications, please call your pharmacy. If you are not being seen for an appt, you may not walk-in and request a refill while we are in clinic with other patients. Please contact our receptionists at ext 0, to have a message sent to our clinic staff. They will need a contact number to return your call and complete a medication encounter (required by Dr Cartwright). We have a 7 day refill policy (you must allow one week for the prescription to be provided). Please plan ahead accordingly. *Pain Medications will not be refilled outside of normal business hours. IT IS NOT APPROPRIATE TO HAVE OUR PROVIDERS PAGED FOR THE PURPOSE OF OBTAINING PAIN MEDICATIONS unless you have had surgery in the past 2 weeks. For non post-op patients, if you have a sudden worsening of pain, you will be directed to the E.R. outside of normal business hours. 2. PAGING SYSTEM: Our office answering service is to be used to page our providers in case of EMERGENCIES ONLY! Please do not call our office staff at home for medical questions. 3. SPECIFIC PHONE LINES: At any time, you may dial 0 to speak with our receptionists. If they are on another line, please leave a message and they will return your call. 0: RECEPTIONIST(s): To schedule/reschedule/cancel an appointment To request a refill on your medication To leave a message for provider assistants (MA/RN) To request medical records 1205 or 1206: Authorizations and Referrals Billing Quesitions? Contact Evans Medical at OFFICE HOURS: We are closed on Fridays. We treat patients on Monday and Wednesday 8:30-5:00 and Tuesday and Thursday 8:30-6:00. Dr Cartwright performs surgeries at Skagit Valley Hospital in Mt Vernon and at Skagit Island Orthopedics in Mt Vernon. 5. NO-SHOW/ CANCELLATION POLICY: Our Office requires a 24 hour cancellation notice. We have patients on a waiting list that would like to see our providers. We know that emergencies happen, and we will look at each case individually. However, non-emergent cancellations and noshows less than 24 hours will be charged a $50.00 cancellation/no-show fee. This includes ALL patients- even those under L&I Work Claims (effective March 23, 2012 per WAC ). Please help us continue to be efficient in our provision of health care and effective in helping you with your orthopedic needs by giving us 24 hour notice if you cannot make your appointment!
4 6. PAYMENTS: All copayments are required to be paid prior time of service. This is a requirement of your contracted insurance- we are mandated to enforce the requirement. All returned checks will incur an additional $40.00 service charge. Patients have 30 days to pay clinic invoices. We accept cash, checks, MasterCard, Visa, Discover, and Care Credit. Patients without insurance will be required to establish a payment plant with our office. ANY PAYMENT PLAN setup in our office requires a copy of the debit/credit card be kept on file in your records. 7. DIAGNOSTIC TESTS: If the doctor has requested that you receive any type of diagnostic test (MRI, X-ray, Bone Scan, Ultrasound/Doppler study, etc) we ask that you get the test performed as quickly as possible. We prep our charts one to two days prior to your appointment. If your films and/or the reports are not available for your appointment (1) you will be required to bring your films/ disk and copy of the report to your appointment, or (2) your appointment will be rescheduled. 8. GLOBAL PERIODS: Surgeries do not necessarily mean that copays are not incurred. Copays are dependent on your insurance policy, and what treatment you receive at your appt. Please request a copy of our Patient Global Period Sheet, if you would like more information. 9. CONSENT TO RELEASE INFORMATION: I authorize staff of Advanced Orthopaedic Institute to discuss my medical condition / records with people listed below: Name: Phone: Name: Phone: 10. DO NOT RELEASE INFORMATION TO: Name: Phone: Name: Phone: ** We have these policies in place to streamline our service and provide you with the best quality of care. Sometimes even the best planning in our schedule cannot compete with emergent services that our providers are called on to provide, we apologize if that happens during your scheduled appointment. We thank you for your patience when other patients appointments run a little longer than anticipated. You will receive the same quality of care with our providers. Judi Cartwright, MPA, OTR/L Office Manager Signature of Patient (or Pt s Representative/Parent) Date Patient Name (PRINTED NAME)
5 EFFECTIVE 3/23/12 FOR: L&I PATIENTS Previously physician offices were not allowed to charge a no-show fee for patients being seen under Labor and Industry claims. Effective 3/23/12, the Department of L&I changed their policies allowing physician offices to charge ALL patients the same fee, regardless of insurance. Missed Medical Appointments (WAC ) This rulemaking clarifies when and under what circumstance a provider can charge an injured worker for a no show or missed appointment related to the industrial injury on an approved claim. The changes were adopted 2/21/2012 and became effective on 3/23/2012. Other than missed appointments for examinations arranged by the department or self-insurer, a provider may bill an injured worker for a missed appointment if: (a) The provider has a missed appointment policy that applies to all patients without regard as to which insurer or entitlement program may be responsible for payment; and (b) The provider routinely notifies all patients of the missed appointment policy. The implementation and enforcement of the policy is a matter between the provider and the injured worker. ***Missed appointments are patients calling same-day to cancel or reschedule*** THIS IS A $50.00 CHARGE FOR EVERY NO SHOW
6 ADVANCED ORTHOPAEDIC INSTITUTE Office of JEFF CARTWRIGHT, M.D. 103 E. Third St ARLINGTON, WA FAX (Rev November 11, 2011 ) (MEDICAL RELEASE) AUTHORIZATION TO USE OR DISCLOSE HEALTH CARE INFORMATION PATIENT NAME: ADDRESS: DATE OF BIRTH: PHONE#: SSN: ALT PHONE#: PLEASE SEND RECORDS TO: JEFF CARTWRIGHT, M.D / ADVANCED ORTHOPAEDIC INSTITUTE (AOI) 103 E. Third Street ARLINGTON, WA PHONE#: FAX#: REQUEST RECORDS FROM: This request and authorization applies to all my health care information. I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment for sexually transmitted diseases, HIV and/or AIDS, or mental health disorders, or drug and/or alcohol use. If I have been tested, diagnosed or treated for HIV and/or AIDS, sexually transmitted conditions, psychiatric/ mental health disorders, or drug and/or alcohol use, you are specifically authorized to release all my health care information to the person or entity above. Or exclude this information:. This consent is subject to my revocation at any time, except to the extent that action has been taken in reliance thereon, and unless earlier revoked, it shall expire within 90 days from the date of this release. Jeff Cartwright, MD/ AOI may not condition treatment or payment on whether an individual signs this authorization. Information disclosed pursuant to this authorization is subject to redisclosure by the recipient and can no longer be protected by Jeff Cartwright, MD/ AOI. Patient/ Guardian Consent (Print): Signature: Date: (Valid for 90 Days)
7 Advanced Orthopaedic Institute The office of Jeff Cartwright M.D. 103 E. Third St. Arlington, Wa Notice of Privacy Practices This notice describes how medical/protected health information about you may be use 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 (PPS). 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, please do not hesitate to call our Office Manager, Judi Cartwright at ext Acknowledgement of Notice of Privacy Practices I hereby acknowledge that I have received a copy of Advance Orthopaedic Institute s Notice of Privacy Practices. I understand that if I have questions or complaints regarding my privacy rights that I may contact the Office Manager. I further understand that the practice will offer me updates to this Notice of Privacy Practices should it be amended, modified or changed. Patient or Representative Name (please print) Patient or Representative Signature Date Patient refused to sign Office Employee Name and Signature
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David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX:
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Family Practice Center 34445 King Street Row Lewes, DE 19958 302-645-2833
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WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance.
Lorie Jenddryka, MS, LCPC, CH 800 E. Northwest Highway, Suite 500 Palatine, IL 60074 (847) 794-8836 WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work
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Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
Sincerely yours, Rev. 06.10
Welcome to RehabXperience. Thank you so much for choosing us. We recognize that you have a choice of physical therapy centers and greatly appreciate you for choosing us as your outpatient physical therapy
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