Patient Demographic and Information Form

Hess Orthopaedic Center and Sports Medicine, PLC

THIS INFORMATION IS SHARED ONLY FOR TREATMENT, PAYMENT, OR OPERATION ACCORDING TO HIPAA LEGISLATION.

PLEASE DO NOT LEAVE ANYTHING BLANK ON THIS FORM.

PATIENT NAME:

TODAY'S DATE:

DATE OF BIRTH:

SSN:

GENDER: MALEFEMALE

PREFERRED LANGUAGE:

MARITAL STATUS: SINGLEMARRIEDOTHER

PRIMARY CARE PHYSICIAN:

PHARMACY OF CHOICE:(for purposes of electronic prescribing)

RACE/ETHNICITY:

PLACE OF EMPLOYMENT:

HOME ADDRESS, CITY STATE, ZIP CODE:

TYPE OF PHONE NUMBER: HOMEWORKCELL

PHONE:

MAY WE LEAVE A MESSAGE FOR YOU ON YOUR ANSWERING MACHINE?:

YESNO Initial:

PATIENT INSURANCE INFORMATION:(Your insurance card will be scanned into our electronic medical record system)

PRIVATE HEALTH INSURANCEMEDICAREMEDICAIDWORKERS' COMPENSATIONSELF PAY

Birth date of insurance subscriber (if different from the patient):

Non-Covered Services: I understand that the service(s) being provided may be non-covered by my health insurance plan, and that I may be responsible for the entire amount billed for services rendered at Hess Orthopaedic Center and Sports Medicine, PLC and agree to pay for the same. I further understand that payment on charges incurred is due at the time of service or according to the office payment policy, unless other financial arrangements have been made with our business office prior to treatment. I understand that my account will be considered past due if not paid within 30 days of the initial bill. In addition to the principle amount owed, should the account become past due, I agree to pay liquidated damages calculated as 25% of the current principle balance on my account in addition to attorney's fees, court costs and interest at 1.5% from the date of service. I authorize and request that insurance payments be made directly to Hess Orthopaedic Center and Sports Medicine, PLC should they elect to receive such payment.

PATIENT SIGNATURE:

I authorize Hess Orthopaedic Center and Sports Medicine, PLC to release medical information regarding the above named patient to: (Only the names listed below bill be able to obtain medical information about you. This includes your spouse, children, trainer, coach, etc.).

NAME:

TELEPHONE:

RELATIONSHIP TO PATIENT:

NAME:

TELEPHONE:

RELATIONSHIP TO PATIENT:

We will contact the person(s) below in an emergency or if we cannot contact you. If the patient is a minor, please include the name of a legal guardian.

EMERGENCY NAME:

RELATIONSHIP TO PATIENT:

ADDRESS:

TYPE OF PHONE NUMBER: HOMEWORKCELL

PHONE:

I consent to treatment necessary for the medical care of the above-named patient at this facility.

PATIENT SIGNATURE:

DATE:

PARENT/GUARDIAN SIGNATURE:

DATE: