New Patient Paperwork Packet

Guarantor Information

Who is responsible for your bill?
Same as patient*

YesNo
Name

First NameLast Name
SS#
Date of birth

MonthDayYear
Date
Age
Gender
Marital status
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Employer
Employer Phone Number

Area CodePhone Number
Insurance Information
Primary Insurance company*
Policy ID*
Group #
Effective date

MonthDayYear
Date
Subscriber's relationship to patient
Subscriber Name

First NameLast Name
Subscriber SS #
Subscriber Date of Birth

MonthDayYear
Date
Do you have secondary insurance?*

YesNo
Secondary Insurance company
Policy ID
Group #
Effective date

MonthDayYear
Date
Subscriber's relationship to patient
Subscriber Name

First NameLast Name
Subscriber SS #
Subscriber Date of Birth

MonthDayYear
Date

Authorization for Release of Information

Hand + Wrist of Louisville | Dr. Michael C. Nicoson
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I authorize Hand and Wrist of Louisville, PLLC (referred to as “Practice”) to use and/or disclose my/the individual’s individually identifiable health information as described below. I authorize Practice to disseminate my individually identifiable health information as described below to the following.
Who can we speak with about your medical information?*
Please list names and/or companies
Type of information to be released:

I authorize the release of diagnosis(es), prognosis(es), treatment plan(s), history, prescription history, limitations, test results, and other medical information contained in the following types of records:
Medical Records:*

All medical recordsI only want the following parts of my medical record to be disclosed:
Please describe:
Dates of Treatment:*

All dates of treatmentI only want records for the following dates of treatment to be disclosed:
Please specify dates:
Billing Records:*

All billing records, including itemized statements
Patient or legal representative signature*

Clear
Date

MonthDayYear
Date
Relationship to individual if legal representative
Review Notice of Privacy Practices

Hand + Wrist of Louisville | Dr. Michael C. Nicoson
SUMMARY OF PRIVACY PRACTICES: This summary of our privacy practices contains a condensed version of our Notice of Privacy Practices.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your Protected Health Information is kept private.

How will we use or disclose your information? Here are a few examples (for more detail please refer to the full Notice of Privacy Practices):
- To obtain payment for our services
- In emergency situations
- For appointment and patient recall reminders
- To run our Practice more efficiently and ensure all our patients receive quality care
- For reasearch
- To avert a serious threat to health or safety
- For organ or tissue donation
- For workers’ compensation programs
- In response to certain requests arising out of lawsuits or other disputes
If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

You have certain rights regarding information maintained in your records. These rights include:
- The right to inspect and copy
- The right to amend
- The right to an accounting of disclosures
- The right to request restrictions
- The right to a paper copy of this notice
- The right to request confidential communications
For more information about these rights, please see our detailed Notice of Privacy Practices.

ACKNOWLEDGEMENT: I hereby acknowledge that I have reviewed a summary of the Notice of Privacy Practices of Hand and Wrist of Louisville, PLLC (the “Practice”). I further acknowledge that I can request to see the detailed Notice of Privacy Practices, that a copy of the current Notice of Privacy Practices will be posted on the Practice’s website, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment.
Patient or personal representative signature*

Clear
Name*

First NameLast Name
Date

MonthDayYear
Date

Office Policies

Hand + Wrist of Louisville | Dr. Michael C. Nicoson
It is the policy of Hand and Wrist of Louisville, PLLC to bill your insurance carrier as a courtesy to you; however you are responsible for the entire bill. We require that arrangements for payment of your estimated share be made today. The insured/patient is responsible for any co-payments at the time service is rendered. If your insurance carrier does not remit payment within sixty (60) days, the balance will be due in full from you. If your insurance pays in excess of the balance of your account, we will refund the credit.

If any payment is made directly to you for services billed by Hand and Wrist of Louisville, PLLC you recognize an obligation to promptly remit same to Hand and Wrist of Louisville, PLLC.

The above does not apply for those patients that are considered Workers’ Compensation. However, be advised as a Worker's Compensation patient that you may be held responsible for your charges in the event that your claim is controverted.

I understand and agree that if I fail to make any of the payments for which I am responsible for in a timely manner, after such default and upon referral to a collection agency or attorney by Hand and Wrist of Louisville, PLLC, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees.

Cancellation / No Show Fee: There will up to a $50.00 no show fee that you will be responsible for if you no-show to a scheduled appointment. We expect 24 hours notice of a cancellation or change to your appointment.

Consent to Wireless Telephone Calls: If at any time I provide a wireless telephone number at which I may be contacted, I consent to receive calls or text messages, including but not restricted to communications regarding billing and payment for items and services, unless I notice Hand + Wrist of Louisville in writing. In this section, calls and test messages include, but are not restricted to pre-recorded messages, artificial voice messages, automative telephone dialing devices or other computer assisted technology, or by electronic mail, text messaging or by any other form of electronic communication from Hand + Wrist of Louisville, its affiliates, contractors, servicers, clinical provers, attorneys, or its agents including collection agents.

Consent to Email Usage: If at any time I provide my email address at which I may be contacted, unless I notice Hand + Wrist of Louisville in writing. I consent to receiving communications regarding billing and payment for items and services at that email address from Hand + Wrist of Louisville, its affiliates, contractors, servicers, clinical provers, attorneys, or its agents including collection agents.

Insurance/Disability or FMLA Forms: Your employer, insurance carrier, accident/sickness insurance, etc. may ask you to complete a disability, FMLA or other form which requires information regarding your care from a physician. A charge of $50.00 for disability forms or FMLA forms will be charged prior to completion of forms. Please allow up to 7 business days for completion (NOTE: A signed medical release will also be required before releasing any forms If forms are needed sooner than 7 business days, there will be an additional charge of $25.00. Please allow 48 hours for completion. If you are submitting insurance/disability forms for an upcoming surgery, the paperwork will not be completed and/or submitted until after the surgery has taken place.

Audio/Video Recording: Audio and video recording is not permitted anywhere in the office.

The above information has been read and explained to me.

I UNDERSTAND MY RESPONSIBILITY FOR THE PAYMENT OF MY ACCOUNT.
Patient or personal representative signature*

Clear
Name*

First NameLast Name
Date

MonthDayYear
Date

Consent to Receive Text Message
I, authorize Hand and Wrist of Louisville to communicate with me and use my protected health information (PHI) for purposes of treatment, payment, and healthcare operations, as described in the Notice of Privacy Practices. This consent specifically applies to the communication methods and topics indicated below.

Appointment Reminders, Reschedules and Cancellations

I understand that Company can reach me any time to remind me of my appointments or let me know in case of any change about my appointments. And I also understand that the Company can employ and use a third-party automated system to reach out to me for the purpose of "confirm", "reschedule" or "cancel".

Contact Information Change

I accept that I am responsible of notifying the Company when my contact information changes.

Consent Cancellations

I know that I can revoke this consent at any time by contacting Hand and Wrist of Louisville.
I consent to the use of mobile phone communications:*

YesNo
I consent to the use of texting (messages) communications.*

YesNo
I sign this consent form on behalf of:*

MyselfSomeone elseLegal Guardian
Name*

First NameLast Name
Phone Number for Text Messages*

Area CodePhone Number
Signature*

Clear
Date*

MonthDayYear
Date

Patient Portal Information

Hand + Wrist of Louisville | Dr. Michael C. Nicoson
The Patient Portal is designed to improve physician and patient communication. Once you are registered as a patient and have provided us with your secure email you will be assigned a username and password. After you registered with the Patient Portal you will be allowed the following:
- Update your contact information
- Request your own appointments
- Request prescription refills
- View your medical summary, treatment history and past appointment dates
- Receive reminders through your email
- View current and past statements
The following will NOT be accepted through Patient Portal:
- Receiving advice on the best course of treatment for your medical problem. All diagnosis will be made by your provider when you are seen for an office visit.
- Request for narcotics/controlled medications.
- Request to refill for a medication not currently being prescribed by Hand and Wrist of Louisville
Online communications should never be used for life threatening, emergency communications or urgent requests. If you have an emergency or an urgent request, you should contact 911 or your physician via telephone.

To learn more or to sign up, contact our office today at (502) 409-6898. The website is:
Reminders for Patient Portal:
- You will have 3 failed log in attempts before the account is locked
- You will be receiving reminders via email from reminders@eclinicalmail.com regarding your appointments. Please make security adjustments to your email or computer to receive our emails.
- You will not be able to reply to our email reminders from reminders@eclinicalmail.com.
- If you haveany questions regarding these emails please send us a message via Patient Portal.
- If you forget your password you may request another one through Patient Portal by clicking on the “Forgot Password” link.
- After you are finished accessing Patient Portal be sure to logout and close your browser. This reduces the risk of someone else accessing your private information.
- Avoid using a public computer to access Patient Portal.
- Patient Portal is provided as a courtesy service for our patients. There is no service fee. However if the patient abuses or misuses Patient Portal we reserve the right to terminate the patient’s account.
- Our hours of operation are 8:00 am - 4:30 pm Monday-Friday. We encourage you to use the web site at any time; however messages are held for us until we return the next business day. Messages are typically handled within 2 business days.
- We reserve the right to suspend or terminate the patient portal at any time and for any reason.
How the Secure Patient Portal Works:

A secure web portal is a type of webpage that uses encryption to keep unauthorized persons from reading communications, information, or attachments. Secure messages and information can only be read by someone who knows the right password or pass-phrase to log in to the portal site. Because the connection channel between your computer and the website uses secure sockets layer technology you can read or view information on your computer, but it is still encrypted in transmission between the website and your computer.
Protecting Your Private Health Information and Risks:
This method of communication and viewing prevents unauthorized parties from being able to access or read messages while they are in transmission. No transmission system is perfect. We will do our best to maintain electronic security. However, keeping messages secure depends on two additional factors:
1. The secure message must reach the correct email address, and
2. Only the correct individual (or someone authorized by that individual) must be able to have access to the message.
Only you can make sure these two factors are present. It is imperative that our practice has your correct e-mail address and that you inform us of any changes to your e-mail address.

You also need to keep track of who has access to your email account so that only you, or someone you authorize, can see the messages you receive from us. You are responsible for protecting yourself from unauthorized individuals learning your password. If you think someone has learned your password, you should promptly go to the website and change it.
Patient Acknowledgement and Agreement:
I acknowledge that I have read and fully understand this consent form and the Policies and Procedures regarding the Patient Portal that appears at log in. I understand the risks associated with online communications between my physician and me, and consent to the conditions outlined herein. In addition, I agree to follow the instructions set forth herein, including the Policies and Procedures set forth in the log in screen, as well as any other instructions that my physician may impose to communicate with patients via online communications. I understand and agree with the information that I have been provided.
Would you like to sign up for the patient portal?*

YesNo
Secure Email Address:
example@example.com
Name

First NameLast Name
Patient Signature:

Clear
Date of birth:

MonthDayYear
Date
Date:

MonthDayYear
Date
Should be Empty:

Patient Information

Emergency Contact

Pharmacy

Primary Care Physician

Employment

Guarantor Information

Insurance Information

Health History

Work Restrictions

Authorization for Release of Information

Review Notice of Privacy Practices

Office Policies

Consent to Receive Text Message

Patient Portal Information

Protecting Your Private Health Information and Risks:

Patient Acknowledgement and Agreement: