Dear Patient: Please Fill out All of The

Dear Patient: Please fill out all of the Doctor______

Information on the front and back of this page New / Update Account______

Your legal name (First, Middle, Last) Today’s Date

Address (mailing address) City, State, Zip-codeHome Phone

Email address (Not a secure form of communication, privacy not guaranteed)Work Phone

SexAgeDate of BirthSocial Security NumberCell Phone

M F

Marital Status:Employment Status Employer

Never Married Separated Widowed Full Time Self Retired Student

Married Divorced Part Time Unemployed Military Disabled

Are there family members to whom we may disclose

your healthcare information? Yes No

If yes, please list their relations, names and phone numbers

Name RelationshipPhone (may we leave a message?) Yes No

Name RelationshipPhone (may we leave a message?) Yes No

Who referred you to this office?Have any of your family been treated by our physicians? If yes, who?

Companion/Spouse or Parent’s nameOccupationName of Employer/Phone number

Social Security NumberDate of BirthPhone Number

Person Responsible for Bill: (if other than parent)Relation to parentHome Phone Number

Address (mailing address, City, State, Zip-Code)

Health Insurance Information

Primary Insurance CompanyPolicyholder’s nameEffective Date

Company’s addressPolicy Number

Secondary Insurance CompanyPolicyholder’s nameEffective Date

Company’s addressPolicy Number

Worker’s Compensation

Insurance Carrier’s Name and AddressClaim Number

Employer’s Name and Phone Number at time of injuryDate of Injury/AccidentLocation of accident

Are you working now? Yes NoHow many years on this job?Have you filed a claim with your employer?

If no, date last worked?

Auto Insurance Information

If you have been involved in a motor vehicle accident, we need all the following information:

Auto Insurance Information:Date of Injury:______Claim #______

Insured Name: ______Phone______

Insurance Company Name: ______City,State Zip-code______

Thank you for filling out this information

Yellowstone MedicalCenter East, Suite 305E / 2900 12th Avenue North / Billings, MT59101/ (406)237-5750 / Fax (406)237-5745

Permission to release information and assignment

I agree to the following:

1. I hereby authorize Billings Orthopedics and Sports of Billings, Montana to furnish the insurance company, employer or

other payor, or their representative of either myself or the subscriber, or to the referring physician, all medical or financial information which may be requested concerning the patient’s illness, injury or condition.

2. I hereby assign to Billings Orthopedics and Sports all money (no to exceed by indebtedness) to which I am entitled for medical or surgical expense for such charges incurred with Billings Orthopedics and Sports on my behalf or request.

3. I understand that I am responsible for the payment of bills regardless of whether the charges may be covered by insurance or also be the responsibility of some other party.

4. I authorize Billings Orthopedics and Sports to release to the Social Security Administration and Health Care Financing Administration or its carrier any information needed for this or a related Medicare claim.

5. If Billings Orthopedics and Sports engages an attorney to collect fees and charges owed, I will pay the reasonable attorney fees incurred by Billings Orthopedics and Sports in any suit action or subsequent appeal.

Hipaa Patient Privacy Acknowledgement

As of April 14, 2003 the federal government requires that all our patients be made aware of our Notice of Privacy Practices, which explains how we will use your medical information. Our practice is committed to secure the privacy of your health information; therefore, we have posted our practice’s Notice of Privacy Practices in the reception area for your perusal. You are not required to read this Notice, however, we encourage you to do so or ask us for a copy to take with you. We would like your acknowledgement that you have been advised that the practice has such a policy posted.

Patient Communication Request

To respect your privacy, please tell us how you would like us to communicate with you regarding your healthcare e.g, test results, appointment changes, surgery schedule, ect.

If you are not there to take our call, do you want us to leave a message?

Home:______Yes No

Work:______Yes No

Cell Phone:______Yes No

Release of information to others:

Unless you object, we may disclose to a family member, other relative, or a close personal friend, or any other person you identify, protected health information directly relevant to that person’s involvement with your care or payment related to your care. We will also disclose protected health information to an individual if we reasonably infer from the circumstances, based on the exercise of professional judgment, that you do not object to the disclosure.

Signature______Date______

Please Print Name ______

Yellowstone MedicalCenter East, Suite 305E / 2900 12th Avenue North / Billings, MT59101/ (406)237-5750 / Fax (406)237-5745