Patient Consent Form, Intake form & HIPAA Form

Please scroll down to fill out all three forms. The Patient Consent & Acknowledgment form, Intake form and HIPPA form.

Once you submit the form a notification under the submit button will thank you for your submission.

MO/KS Patients

Patient Registration Form

Patient's First name

Patient's Last name

Patient's DOB

Month

Day

Year

Address

Phone

Gender

Male

Female

Other

Parent/Guardian

Primary Care Physician- Phone number- Fax number

Who referred you to Core?

Physical or Occupational Therapist

Doctor

Surgeon

Other

Please provide the name and phone number for the individual/group that referred you to Core.

*It is important that you provide complete and accurate insurance information; if this is not received, you may be held responsible for the full cost of services*

Primary Insurance Carrier

Primary Insurance Policy ID#

Primary Insurance Group #

Primary Policy Holder Name

Primary Policy Holder SS#

Primary Policy Holder DOB

***Tricare only Sponsors DOD#

Secondary Insurance Carrier

Secondary Insurance Policy #

Secondary Insurance Group #

Secondary Policy Holder Name

Secondary Policy Holder SS#

Secondary Policy Holder DOB

Patient Consent & Acknowledgement Form

Patient First name

Patient Last name

Patient DOB

Month

Day

Year

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

I have been given a copy of Core Orthotics and Prosthetics, Notice of Privacy Practices and understand these rights. I also understand

that it is my responsibility to notify the Privacy Officer in writing of any restrictions to my patient file. Forms are available through the

Privacy Officer upon request. The following are people I would like to be involved in or have access to my protected health information

on a routine basis. I give permission for Core Orthotics and Prosthetics to share my protected health information with:

Parent/Legal Guardian Name & Relationship

CONFIDENTIAL/ LIABILITY RELEASE

I hereby consent and grant permission for Practitioners’ employed by Core Orthotics and Prosthetics to discuss my medical

treatment for orthotics and/or prosthetics, with my referring physician, primary care physician, physical therapist, occupational therapist,

hospital and/or rehabilitation staff, relating to my care and treatment. I also understand that it is my responsibility to notify the Privacy

Officer upon request.

CONSENT TO TREAT

I hereby authorize Core Orthotics and Prosthetics, to perform evaluations and/or treatment services on me/my child.

FINANCIAL POLICY

I understand that I am responsible for Payment of charges and that payment is due at the time of services, or I hereby assign

insurance benefits to be paid directly to Core Orthotics and Prosthetics.

I understand that I am responsible for charges not covered by my insurance policy.

I understand that amounts which are 90days past due could be eligible for potential collections and turned over to a Collection

Agency, unless prior arrangements have been made with the Business Administrator. Collection Agency fees are recognized to be the

patient/responsible party(s) responsibility.

I understand that I am responsible for a fee of $25.00 for any returned check.

RELEASE OF INFORMATION & AUTHORIZATION

I hereby consent and permit a copy of this authorization and assignments to be used in place of this original signed document. I

understand that this original will be placed in my patient file to be kept at the medical provider’s office.

I hereby authorize any practitioner examining and/or treating me, to release to any third party (such as an insurance company or

governmental agency) any medical information and records concerning the diagnosis and treatment when requested for use in determining

payment of claims. I understand this is a lifetime release of information unless I have placed restrictions in my patient file and have

completed the necessary forms.

I hereby consent and authorize Core Orthotics and Prosthetics, to file claims for treatment, electronically or manually, to my

insurance carrier(s) for service rendered to me.

ASSIGNMENT OF BENEFITS

I hereby consent and authorize payment to be paid directly to the provider, Core Orthotics and Prosthetics for services

rendered for any orthotic and/or prosthetic services and treatment. Any services for which assignment is not accepted are acknowledged

as being my full and complete financial responsibility.

COMPLAINT RESOLUTION PROTOCOL

I have been informed of Core Orthotics and Prosthetic’s Complaint Resolution Protocol.

WARRANTY

All orthoses are covered by a warranty period of 90days for workmanship and materials. I have read, understand and agree to all

of the above.

By typing my name below, I acknowledge that this typed entry represents my electronic signature. I understand and agree that my electronic signature is legally binding and has the same force and effect as a handwritten signature. I confirm that the information provided in this form is accurate to the best of my knowledge.

Patient/Parent/Legal Guardian Signature

Today's date

HIPAA Compliance & Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

• The practice reserves the right to change the privacy policy as allowed by law.

• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

• The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm appointments?

Yes

May we leave a message on your answering machine at home or on your cell phone?

Yes

May we discuss your medical condition with any member of your family?

Yes

If YES, please name the members allowed:

Signature

Today's date