Serving Central Ohio's prosthetic and orthotic needs since 1970.
Looking back with pride, looking forward with purpose.
Name (required) Phone:
Gender: Male Female
SSN: Date of Injury:
Nursing Home: Yes No
Nursing Home Phone:
Employer Address: Employer Phone:
Next of Kin: Kin Address:
Primary Care Physician: Address: Phone:
Prescribing Physician Address:
Prescribing Physician Phone:
Guarantor (if different from patient):
Guarantor DOB: Guarantor Employer:
Group Plan: Policy ID:
Is this an industrial injury? Yes No Injury
Insurance Claim: Date:
Payment for services: Cash Check Credit Card
IF Patient is a MINOR, please fill out this section:
I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered. I certify this information is true and correct to the best of my knowledge. I will notify American Orthopedics, Inc. of any changes in my insurance status or the above information.
I understand that American Orthopedics, Inc. will fill the prescription from my physician as written. Other than slight modifications for comfort, they will not alter the basic prescription without direct orders from the physician. The professional staff at American Orthopedics, Inc. is comprised of orthotists and prosthetists, and as such, they render, but do not prescribe orthotic and prosthetic care.
I understand that there is no guarantee that I will be successful in the use of the prescribe treatment. I understand that American Orthopedics, Inc. will make reasonable effort to make the prescribed treatment acceptable to me, however, I recognize that this prescribed work is of a custom make nature and agree to be financially responsible for this care, regardless of whether or not I can successfully function with it. This is not unlike a pharmacist filling a prescription, in that a pharmacist is unable to guarantee a prescribed regime of care will be successful.
Prosthetic Patient Medical History
Name: Today's Date:
Medical Complications: Diabetes Diabetes Heart Disease Arthritis Mental Disease Serious Visual Impairment Obesity Other Other:
Previous surgeries related to your present conditions. Please explain below.
Diagnosis/Cause of Amputation:
Site of Amputation: Side:
Date of Amputation:
Name of Surgeon: Location:
Manufacturer: Results: Satisfactory Unsatisfactory
If unsatisfactory, please specify:
Have you received prosthetic training?: Yes No
If yes, from whom?
New Patient Consent to the Use and Disclosure of Health Information for Treatment, payment, or Health Care Operations
I understand that as part of my health care, American Orthopedics originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
I understand that American Orthopedics is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this Consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.
I further understand that American Orthopedics reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the code of Federal Regulations. Should American Orthopedics change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or, if I agree, e-mail).
I wish to have the following restrictions to the use or disclosure of my health information:
I wish to be contacted in the following manner: Ok to leave message Leave call back number only
Ok to leave message Leave call back number only
I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I Consent to such disclosure for these permitted uses, including disclosures via fax.
I fully understand and accept the terms of this Consent.