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8854 W EMERALD, STE 140
BOISE, ID 83704
- You have been asked to fill out our patient information sheet. The accuracy of this
information is very important. Please print clearly. Please give your given name, with initial as it appears on
your insurance card. If you go by a different name, please let us know by putting it in () by your name card. HOSPITAL PATIENTS
- You have received this letter and form in the mail and probably have not been to
our office. Please fill out this form and return it to the office, an envelope is provided. This will insure that we
have the correct billing information. PAYMENT OF SERVICES
- You and/ or your insurance company should settle your bill in full within 60
days. We accept Visa, Mastercard, or Discover. In the event of an overpayment a refund will be sent to you. INSURANCE
- Your insurance will be filed for you based on the information you have given on the attached
form. Please keep the billing office informed of any changes in your insurance. We will file both your primary
and secondary insurance. Insurance is filed for your courtesy. You are responsible for the bill regardless of
your insurance. If your insurance does not pay within four weeks, please contact them. The billing office staff
is available to assist you with any insurance problems. Some insurance problems require your attention. Please
feel free to contact us at 375-2782 between 8:00 AM and 4:00 PM Monday through Friday. This phone is for
billing and insurance questions only. NETWORKS
- There are a variety of HMO and PPO Networks available through your insurance company.
We do not participate with all insurance plans. It is your responsibility to check with your insurance company
and with the billing office to be sure the physician you are seeing is a member of your network. MEDICARE
- We are participating providers with Medicare. Medicare will send the payment directly to us.
Please sign the Medicare Authorization in addition to the patient information form. Please provide us with your
secondary insurance information so we may bill it for you. You will be responsible for any balance up to the
Medicare allowable that is not paid by Medicare and your secondary insurance. PRIVATE MEDICARE PLANS
(True Blue, Healthsense 65, Humana Gold Choice, Secure Horizons)
We are not contracted with all private Medicare plans. You will need to contact our billing office at 375-2782
to verify your particular plan is one we can bill. TRICARE
- We are not accepting new Tricare patients at this time. If you have been seen through the
hospital, we will bill Tricare for you. You will be responsible for any copays, deductibles, or cost share
- You will receive an itemized bill from us. It will indicate if you insurance has been billed.
We realize that medical bills are usually unexpected. These situations may make it difficult for you to pay in
full within 60 days. Please do not ignore the bill. The doctor has given you care and will extend credit to you.
We are willing to allow you to make monthly payment, but those payments must be arranged through our billing
office. Please call our billing office at 375-2782 to make payment arrangements. We will be available to
answer any questions or concerns about your bill.
WELCOME TO ORTHOPAEDIC ASSOCIATES
PLEASE FILL OUT EACH SECTION C0MPLETELY -- THANK YOU
NAME (if married)
NAME (if minor)
NAME (if minor)
WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE
PLEASE CIRCLE ONE: INSURANCE WORKER'S COMP AUTO OTHER SELF-PAY MEDICARE MEDICAID
WERE YOU INJURED IN AN AUTO ACCIDENT? YES NO
INSURANCE COMPANY NAME
INSURANCE COMPANY NAME
NEAREST FRIEND/RELATIVE NOT LIVING WITH YOU
I authorize Orthopaedic Associates to render treatment. I authorize Orthopaedic Associates to release/obtain
any medical records/x-rays from any medical care providers and my insurance carrier to facilitate processing
of my claims. I authorize my insurance carrier to pay all benefits directly to Orthopaedic Associates. This
authorization shall continue to be in force and effect until revoked in writing by me. By signing, I acknowledge
that I am ultimately responsible for any and all charges incurred by this office.
SIGNATURE (SIGNATURE OF PATIENT, OR PARENT/GUARDIAN IF UNDER 18)
Thank you for choosing Orthopaedic Associates, P.A. for your orthopedic care. We are dedicated to ensuring you receive the best care available. In return our patients are financially responsible for the services we provide. We bill your insurance carrier with the information given us and make every effort to collect for services rendered. However, payment is still expected within 90 days from the date of service. We require co-payments, deductible amounts and non-covered services be paid for at the time of service. We are participating with Medicare and accept assignment on your claims. We will bill Medicare and any supplemental policy you may have first. Once they have processed and paid your claims we will then send you a bill for any balance remaining. For our patients without health insurance coverage we do require a payment of $150.00 at the initial visit. We will then require monthly payment arrangements be made on any unpaid balance and a minimum payment be made at each additional visit. Surgical services do require a deposit based on estimated costs 48 hours prior to the scheduled procedure. Monthly payment arrangements must then be made on the balance. You will be required to sign a payment contract if surgery is needed. We accept cash, check and major credit cards for your convenience. The billing department is available from 8:30 am- 4:30 pm Monday through Friday to address any concerns or questions you may have. By signing and dating below, I acknowledge I have read and understand and will comply with the above policies. _______________________________ ________________________ Signature Date
ORTHOPAEDIC ASSOCIATES NOTICE OF PRIVACY PRACTICE
EFFECTIVE DATE: APRIL 14, 2003
THIS NOTICE DECRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY:
We understand that medical information about you and your health is personal. Orthopaedic Associates is required by law to maintain the privacy of your health
information, to follow the terms of this Notice, and to provide you with this notice of our legal duties and privacy practices with respect to your health information. We
are required to follow the terms of the Notice that is currently in effect. A paper copy of this notice may be obtained upon request.
How Orthopaedic Associates May Use or Disclose Your Health Information:
Orthopaedic Associates protects the privacy of your health information. We must have your written authorization to use or disclose your health information. However, the law permits Orthopaedic Associates to use or disclose your health information for the following purposes without your authorization:
- Information obtained by Orthopaedic Associates will be used for medical treatment or services. We may disclose health information about
you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you and your health.
- We may use and disclose your health information about you so that treatment and services you receive at this office may be billed to and
payment may be collected from you, an insurance company or third party.
For Health Care Operations
- We may use and disclose health information about you in order to run the office and make sure that you and our other
patients received quality care.
As Required by Law
- We will disclose health information about you when required to do so by federal, state or local law.
To avert a Serious Threat to Health or Safety
- We may use and disclose health information about you when necessary to prevent a serious threat to your
health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the
Public Health Risks
- We may disclose health information about you for public health reasons in order to prevent or control disease, injury or disability;
suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.
For Health Oversight Activities
- We may disclose health information to a health oversight agency for activities authorized by law. These oversight
activities, which are necessary for the government to monitor the health care system, include audits, investigations, inspections and licensure.
Lawsuits and Disputes
- If you are involved in a lawsuit or dispute, we may disclose health information about you in response to a court order or
administrative order. We may also disclose health information about you in response to a subpoena, discovery request or other lawful process by someone
else involved in the dispute, but only if efforts have been made to tell you about the request ( which may include written notice to you) or to obtain an order
protecting the information requested.
For specific Government Functions
- Orthopaedic Associates may disclose health information for the following specific government functions (1) health
information of military personnel, as required by military command authorities; (2) health information of inmates, to a correctional institution of law
enforcement official; (3) in response to a request from law enforcement, if certain conditions are satisfied; and (4) for national security reasons.
When Orthopaedic Associates May Not Use or Disclose Your Health Information:
Except as described in this Notice, Orthopaedic Associates will not use or disclose your health information without your written authorization. If you do authorize Orthopaedic Associates to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
You Have the Following Rights With Respect to Your Health Information:
You have the right to request restrictions on certain uses and disclosures of you health information. Orthopaedic Associates is not required to agree to a restriction that you request. If we do agree to any restriction, we will put the agreement in writing and follow it, except in emergency situations. We cannot agree to limit the uses or disclosures of information that are required by law.
You have the right to inspect and copy your health information as long as Orthopaedic Associates maintains the health information. Your health information usually will include your medical records and billing records. To inspect or to receive a copy of your health information, you must submit a written request to 901 N Curtis Rd, Ste 501, Boise, Idaho 83706. We may charge a fee for the costs of copying, and mailing, that are necessary to grant your request. We may deny your request to inspect and copy in certain limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. You have a right to choose to obtain a summary instead of a copy of your health information.
You have the right to request that Orthopaedic Associates amend your health information that is incorrect or incomplete. To request an amendment, you must submit a written request to the privacy officer, Marilyn Nelson, 901 N Curtis Rd Ste 501, Boise, Idaho 83706, along with the reason for the request. Orthopaedic Associates is not required to amend health information that is accurate and complete.
You have the right to receive an accounting of disclosures of your health information we have made April 14, 2003 for purposes other than disclosures.
(1) for Orthopaedic Associates treatment, payment or health care operations, (2) to you or based upon your authorization and (3) for certain government functions. To request an accounting, you must submit a written request to 901 N Curtis Rd, Ste 501, Boise, Idaho 83706. You must specify the time period, which may not be longer than six years.
You may request communications of your health information by alternative means or at alternative locations. For example, you may request that we contact you about your health matters only in writing or at different residence or post office box. To request confidential communication of your health information, you must submit a written request to Orthopaedic Associates. Your request must state how or when you would like to be contacted. We will accommodate all reasonable requests.
Changes to this Notice of Privacy Practices:
Orthopaedic Associates reserves the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we have
about you as well as any information we receive in the future. Any revised Notice will be posted in the front office of Orthopaedic Associates. Upon request, we will
provide a revised Notice to you.
For More Information or to Report a Problem:
If you have questions or would like additional information about Orthopaedic Associates privacy practices, you may contact the Privacy Officer, Marilyn Nelson, 901 N Curtis Rd Ste 501, Boise, Idaho 83706 or phone 208-378-2868 or FAX 208-367-2877. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer above or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.
Acknowledgement of Receipt of Notice
Marilyn Nelson, Privacy Officer, 208-367-2868
I hereby acknowledge that I received a copy of this medical practice’s Notice of Privacy Practices. Would you like to receive a copy of any amended Notice of Privacy Practices: Yes No (circle one)
write your e-mail or mailing address to send the amended notice to: _________________________________
Signed: ________________________________ Date: _____________
Print Name: ____________________________
If not signed by patient, please indicate relationship
Guardian or conservator of an incompetent patient
Beneficiary or person representative of deceased patient
Name of Patient: ________________________________________________
_____________________________________________________________________________________ For office Use Only:
Signed form received by: ___________________________________
Reasons for refusal: _________________________________________________________________
MEDICAL HISTORY SHEET – DR DOERR
Patient Name: ______________________________________
REFERRING MD – Which doctor referred you to our office?________________________
PAST MEDICAL HISTORY – (Check all that apply). If NONE, write NONE.
High Blood Pressure
Congestive Heart Failure
Lung Disease (specify)
Liver Disease (specify)
Kidney Disease (specify)
PAST SURGICAL HISTORY – Please list all surgeries you have had and the year they were performed including tonsils,
appendix, gall bladder, orthopaedic surgeries, etc, If none, write NONE. SURGERY
MEDICATIONS – Please list all the medications you are taking and specify dosages as how many times a day you take
them. Include over-the-counter medications and anti-inflammatories such as Aspirin, Motrin, Naprosyn, Ibuprofen,
Aleve, Lodine, Relafen, etc. If none, write NONE.
DOSE (MG., MCG., ML)
REASON FOR USE
ALLERGIES – Please list all allergies you have including medication allergies. If none, write NONE.
SOCIAL HISTORY -
How many cigarettes do you smoke per day? If none, write NONE. __________________
2. How much alcohol do you drink per day? If none, write NONE. _____________________
Have you ever experimented with non-prescribed drugs? If none, write NONE_________
Do you have any tattoos? If none, write NONE__________
BP__________ PULSE_________ RESP__________ HT_________ WT___________
Combined Prescriber-Patient Agreement & Informed Consent This consent and agreement for treatment between the undersigned patient and prescribers at Innovative Medicine is to establish clear conditions and consent for the prescription and safe use of pain control ing opioid medications or other control ed substances prescribed by the healthcare provider for the patient. These medica
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