TAYLOR REGIONAL ORTHOPEDICS
1698 Old Lebanon Road Suite 3A
Campbellsville, KY42718
Date______
PATIENT INFORMATION
Name______Soc Sec______
Last Name First Name Initial
Address______Home Phone______
City______State______Zip______
Sex ______M ______F Age______Birth date ______Single ______Married ______Widowed ______Other______
Patient Employed by ______Occupation ______
Business Phone______Whom may we thank for referring you?______
In case of emergency who should be notified? ______Phone______
GUARANTOR INFORMATION
Person Responsible for Account______Relation to Patient ______
Last Name First Name Initial
Address (if different from patient's)______Phone______
City ______State______Zip______
Guarantor Birth date______Guarantor Soc Sec______Employer______
INSURANCE INFORMATION
Insurance Company______Subscriber Name______
Subscriber Employed By ______Subscriber Soc Sec ______Birth date______
Contract # ______Group # ______Subscriber Id#______
ADDITIONAL INSURANCE
Is patient covered by additional insurance? ____Yes ____No Is today’s visit related to an accident? ______Work Related?______
Subscriber Name______Relation to Patient______Birth date______
Subscriber Employed by ______Business Phone ______
Insurance Company ______Subscriber Soc Sec ______
Contract # ______Group # ______Subscriber Id#______
ASSIGNMENT AND RELEASE
I consent to treatment necessary for the care of above named patient.
I, the undersigned certify that I (or my dependent) have insurance coverage with ______
Name of Insurance Company(ies
and assign directly to Taylor Regional Orthopedics all insurance benefits, if any, otherwise payable to me for services rendered.
I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to
release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions:
______Responsible party signature Relationship Date
Taylor Regional Orthopedic Group
1698 Old Lebanon Road Suite 3A
Campbellsville, Kentucky42718
Phone 270-465-0632
Fax 270-465-0539
PRESCRIPTION DRUG POLICY
PLEASE READ CAREFULLY
- Class II and Class III narcotics are prescribed on a short-term basis. The patient will receive a firm cut off date in which no more medications of this type will be prescribed.
- Patients who are prescribed anti-inflammatory medications who are not seen on a monthly basis will be evaluated every 6 (six) months.
- Prescriptions WILL NOT be refilled when the physician does not have access to your chart. Prescriptions will not be refilled after office hours, weekends, or holidays.
- Our office will only take refill requests for patients seen in the Campbellsville clinic. This means that you cannot call the Bardstown or Louisville to request a refill and expect it to be filled.
- Prescription refills should be called to the office by your pharmacy and allow at least 48 (forty-eight) hours for the pharmacy to be contacted as the physicians are not in our office daily. If the patient contacts our office to initiate the refill, we will take a verbal request from the patient only (in the case of a child under the age of 18, we will take a verbal request from the parent or legal guardian)
- Lost, stolen, or discarded prescriptions WILL NOT be refilled.
- Prescriptions requests WILL NOT be taken if the patient has been discharged from care or returning on “as needed” basis.
- Prescription requests WILL NOT be filled if the patient has cancelled or failed to keep an appointment since the last visit.
- Lortab and Vicodin are given only post operatively and post acute fractures for a total of six (6) weeks only.
- Our office does not prescribe Oxycontin.
By signing below, I certify that I have read and fully understand the contents of the prescription policy and agree to honor the terms of the policy.
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Signature of patient/representativeDate
Taylor Regional Orthopedic Group
1698 Old Lebanon Road Suite 3A
Campbellsville, Kentucky42718
Phone 270-465-0632
Fax 270-465-0539
CONSENT FOR TAKING AND PUBLICATION OF PHOTOGRAPHS, VIDEOS, AND FILMS
In connection with the medical services I am receiving, I consent that photographs, videos, and / or films may be taken of me or parts of my body, under the following conditions.
- Photography, in the context of this consent, means photographs, videos, and / or films.
- The photography may be taken only with the consent of my physician and under such conditions and at such time as may be approved by my physician.
- The photography shall be taken by my physician or by a staff member approved by my physician.
- The photography shall be used for medical records and if in the judgment of my physician, medical research, education or science will be benefited by their use, such photography and information relating to my case may be published and republished, either separately or in connection with each other, in professional journals or medical books, or used for any other purpose which he may deem proper in the interest of medical education, knowledge or research: provided, however, that it is specifically understood that in any such publication or use I shall not be identified by name.
- The aforementioned photography may be modified or retouched in any way that my physician, in his discretion, may consider desirable.
- The photography may be published or republished in the hospital newsletter / journal or released by the hospital to the press for publication in newspapers, journals, magazines, or any other media the hospital deems appropriate.
Signed: ______
(patient or person authorized to consent for the patient)
______
(relationship to the patient)
______
Date Signature of witness
Taylor Regional Orthopedic Group
1698 Old Lebanon Road Suite 3A
Campbellsville, Kentucky42718
Phone 270-465-0632
Fax 270-465-0539
ENCOUNTER FORM INFORMATION DISCLAIMER
I certify that all information completed is correct to the best of my knowledge. I will not hold Taylor Regional Orthopedics Group or any member of its staff responsible for any errors or omissions that I may have made in the completion of all forms.
______
Patient name (print please)
______
Patient signature
______
Date
Taylor Regional Orthopedic Group
1698 Old Lebanon Road Suite 3A
Campbellsville, Kentucky42718
Phone 270-465-0632
Fax 270-465-0539
Dear Patient:
In order to help us stay within the guidelines of HIPAA, please list below any person/persons that you authorize us to disclose information to regarding your Protected Health Information. (You are not required to list any of your doctors)
NameRelationship
1. ______
2.______
3.______
4.______
Do we have your permission to leave information on your answering machine or digital voice mail when you are not at home?
Yes ______No ______
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Patient name (please print) Date of birth
______
Patient signature Date
Taylor Regional Orthopedic Group
1698 Old Lebanon Road Suite 3A
Campbellsville, Kentucky42718
Phone 270-465-0632
Fax 270-465-0539
I acknowledge that I have received a copy of the Notice of Privacy Practices (effective after April 14, 2003) which explains how my protected health information may be used and disclosed for treatment, payment, and healthcare operations.
Patient name: ______
Patient signature: ______
Date of signature: ______
Taylor Regional Orthopedic Group
1698 Old Lebanon Road Suite 3A
Campbellsville, Kentucky42718
Phone 270-465-0632
Fax 270-465-0539
Dear Patient:
I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, or to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. (Section 1128B of the Social Security Act and 31 U.S.C. 3801-3812 provides penalties for withholding information). Regulations pertaining to Medicare assignment of benefits also apply.
I authorize the release of any medical or other information necessary to process claims. I also request payment of government benefits either to myself or to the party who accepts assignment.
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Patient name (please print)
______
Patient signature
______
Date
Taylor Regional Orthopedic Group
1698 Old Lebanon Road Suite 3A
Campbellsville, Kentucky42718
Phone 270-465-0632
Fax 270-465-0539
FINANCIAL POLICY
POLICY STATEMENT
We would like to thank you for choosing Taylor Regional Orthopedics Group and allowing us to provide your healthcare needs. The policies listed herein have been approved by the management with the goal of providing the finest care and service to our patient at the least cost.
Care delivered by this facility will be administered regardless of race, color, creed, social status, national origin, handicap, or sex.
RESPONSIBILITY FOR THE BILL
It is the expectation that all patient/guarantors receiving services are financially responsible for the timely payment of all charges incurred. While this office will file verified insurance for payment of the bill(s) as a courtesy to the patient, the patient/guarantor is ultimately responsible for payment and agrees to pay the account(s) in accordance with the regular rates and terms of this office in effect at the present time.
POINT OF SERVICE COLLECTIONS
Payment for service is due at the time the service is rendered. Payment will be accepted with cash or check. We will be happy to file verified insurance on your behalf.
If your insurance requires a co-payment, it will be due at the time of service. Non payment of a copay at the time of service does not release the patient from responsibility of payment.
If you do not have insurance, we require a $50.00 down payment at the time of service. The remaining balance is referred to the Physician billing department of TaylorRegionalHospital for billing purposes.
Patients unable to comply with the Point of service payment policy will be referred to the Office Manager for necessary arrangements.
PAYMENT ARRANGEMENTS
This office will make a reasonable effort to assist patients in meeting their financial obligations.
SURGERY DEPOSITS
This office may request deposits against the total of charges in cases where the patient does not have insurance, proof of insurance, sufficient insurance, or the insurance does not cover the procedure.
ACCEPTANCE OF INSURANCE
This office will accept “Assignment of Benefits” on verified insurance policies and submit a bill to the carrier on the patient’s behalf. It is understood that insurance is filed as a courtesy and does not relieve the patient of financial responsibility.
SECONDARY INSURERS
Having more than one insurance does not necessarily mean that your services are covered 100%. Secondary insurances willpay as a function of what your primary carrier pays. We will bill your secondary carrier as a courtesy. The patient/guarantor is responsible for any balances after all insurances have cleared.
RELEASE OF INFORMATION
By signing our release of information form, you provide us with the authority to release such information as is necessary to collect from insurance companies and other third party payers.
PATIENT RESPONSBILITY
Balances after insurance are due within 30 days of the insurance payment, unless other satisfactory arrangements have been made with this office.
Our office will obtain authorization with your insurance company for tests that are ordered by our physicians. Our office will not obtain authorization for your initial visit with our doctors. It is the responsibility of the referring doctor to obtain authorization for our services.
Not all services are covered by all insurance companies. It should be understood that by accepting the services, the patient is responsible for payment regardless of the fact that insurance covers the service or not.
This office cannot become involved with any third party liability matters and must always look to the patient/guarantor for payment of the bill.
DIVORCE DECREES
This office is not a party to your divorce decree. Adult patients are responsible for their bill at the time of service. The responsibility for minors rests with the accompanying adult.
MINOR PATIENTS
The adult accompanying a minor on the visit will be responsible for payment or insurance co-payments.
BAD DEBTS
If the account is not paid in full or satisfactory arrangements made within the allowable time frames, this office reserves the right to refer the account to a collection agency for collection of this balance.
The administration and Management welcomes the opportunity to discuss any aspect of the financial policy. We appreciate your confidence and strive to provide quality healthcare.
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By signing below, I agree that I have read and fully understand the financial policy set forth by Taylor Regional Orthopedics Group and I agree to the terms of this financial policy. I also understand and agree that the terms of this policy may be amended by the practice at any time without prior authorization to the patient.
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Patient name (please print) Date of birth
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Patient signature Date
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