New Patient Packet: Neuro

New Patient Packet

Neurosurgery
New Patient Information
Patient Name*

First NameLast Name
Date of Birth

MonthDayYear
Gender*
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Home Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Cell Number*
Please enter a valid phone number.
Consent to text?*
Preferred Method of Contact*
Race*

WhiteAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian/Pacific IslanderDecline to Answer
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoDecline to Answer
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.

Provider and Pharmacy Information
Primary Care Provider
Referring Care Provider
Primary Care Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referring Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Specialists Involved in Care:
Preferred Pharmacy
Preferred Pharmacy Phone
Please enter a valid phone number.
Preferred Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mail-In Pharmacy
Mail-In Pharmacy Phone
Please enter a valid phone number.
Insurance Information
Primary Insurance*
Relationship to Patient*
Insured's Name*

First NameLast Name
Date of Birth of Insured (If different from patient)

MonthDayYear
Social Security Number
If different from patient
Member ID
Insured's Employer
Do you need assistance confirming your insurance or if it is in-network?
Copy of Your Insurance Card - FRONT*

FRONT SIDE
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Copy of Your Insurance Card - Back*

BACK SIDE
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Secondary Insurance
Insured's Name
Date of Birth of Insured (If different from patient)

MonthDayYear
Relationship to Patient
Social Security Number
If different from patient
Member ID
Insured's Employer
Guarantor

Person responsible for the bill if the patient is a minor or student:
Name

First NameLast Name
Relationship to Patient
Social Security Number
Date of Birth

MonthDayYear
Date
Home Number
Please enter a valid phone number.
Mobile Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Acknowledgement

I acknowledge that by providing insurance information, I have asked and promise to pay for services provided in exchange for this information. I assign to Midlands Orthopaedics & Neurosurgery, PA all health insurance benefits available for services provided to me. I understand that fees for services provided by Midlands Orthopaedics & Neurosurgery, PA are my responsibility, and I agree to pay any balance left unpaid by any insurance company or third party entity immediately upon notification of said balance. If I do not have insurance, I understand that I am responsible for any incurred expenses in their entirety.
Signature

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HIPAA PRIVACY AUTHORIZATION

I hereby authorize Midlands Orthopaedics & Neurosurgery, PA, to use and/or disclose the protected health information below to:
[Name of individual (i.e. spouse, family member, doctor, etc.), address, and telephone number]
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to Patient
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorization for Release of Information:
Covering the period of healthcare from:

MonthDayYear
Date
To:

MonthDayYear
Date
OR

All past, present, and future periods
- I understand that I have the right to revoke this authorization, in writing, at any time.
- I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
- I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned upon signing this authorization.
- I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Signature

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Today's Date

MonthDayYear
Date
Name of Patient or Personal Representative*

First NameLast Name
Relationship to Patient*
Consent Form
We will need your signed consent form before your office visit. This signature represents that you understand the risks involved with knee arthroplasty. Please find the consent form here. Print, read, sign, and upload below. If you are unable to upload now, we ask that you at least review so that you are ready to sign at your appointment.

Signature: I have reviewed the above and understand the risks involved with this operation. I would like Dr. Thomas Gross to perform hip arthroplasty on me. *
Signature

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OR
Upload signed consent form

Please review and sign to express that you have read and understand risks associated with hip arthroplasty. These consent forms can be found at grossortho.com under the "Pre-operative patient" forms page.
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MIDLANDS ORTHOPAEDICS & NEUROSURGERY (MON) AUTHORIZATIONS AND ACKNOWLEDGEMENTS
1. NOTICE OF PRIVACY POLICIES: I have been offered a copy of the MON Notice of Privacy Policies detailing how my protected health information (PHI) may be used and disclosed as permitted under federal and state law. I understand that MON is permitted to disclose my PHI without my authorization to facilitate treatment, payment and health care operations. This notice is always available on the MON website (www.midorthoneuro.com) and at each office location upon request.

2. FINANCIAL POLICY: I have been offered a copy of the MON Financial Policy and acknowledge its requirements. This notice is always available on the MON website (www.midorthoneuro.com) and at each office location upon request.

3. ePrescribe: I understand that MON utilizes electronic health record software which incorporates ePrescribing technology. I understand that MON may access and use my prescription history through ePrescribing software to facilitate appropriate treatment.

4. PAPERLESS BILLING: MON delivers paperless billing statements via our patient portal. I understand that I am automatically enrolled to receive paperless billing statements via the email address provided at registration. Changes to statement preferences may be made via the patient portal at any time.

5. PATIENT PORTAL: The patient portal is the most efficient tool to securely request appointments and communicate with our staff members, allowing you to bypass our phone system completely. Registering by smartphone is fast and easy. Ask the front desk staff to send a text with the registration link. Use the link and temporary password to login. You may also follow the Patient Portal link on our website (www.midorthoneuro.com) and click “Sign Up Today.” You will need to enter your name, date of birth and email address as they appear in your MidOrthoNeuro account.

I acknowledge understanding of the items described on this Authorizations & Acknowledgements form.
Signature

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Today's Date

MonthDayYear
Date
Midlands Orthopedics & Neurosurgery, P.A. Financial Policy
Thank you for choosing Midlands Orthopaedics & Neurosurgery, PA (MON). We recognize that healthcare is expensive, insurance requirements are frustrating and discussing payment arrangements may be unpleasant. Nevertheless, unexpected charges or bills are also unpleasant, so we ask you to review our finacial policies. As your health care provider, our relationship is with you -- our patient -- not with your insurance company. Your insurance plan is a contract between you, your insurance company and/or your employer. Our office is not a party to that contract or any possible restrictions imposed by it. While we will make every effort to obtain appropriate payment from your insurance carrier, payment for services renderede is ultimately your responsibility.

Payment for Services: Copays will be collected at check-in, as well as any balance due on the account. We will pre-collect the estimated patient responsibility amount for surgeries, procedures, and diagnostic services.

Insurance: You will be required to update your insurance information at least once annually, but we may ask you to provide your insurance card more frequenty. Please notify our office immediately if you change insurance carriers, drop coverage, receive new cards or in any way experience a change to your coverage. Failure to do so may result in insurance claim denials that cause all charges to become your full resposibility. Please know the benifits, limitations, and responsibilities of your insurance plan.

Referrals and Authorizations: If your plan(s) require a referral from your primary care physician (family or regular doctor), pplease make sujre one has been provided prior to your appointment. We must have a current referral to prevent your insurance carrier from denying payment for services you receive with us.

Patient Out-of-Pocket Expenses: We participate with many health plans and file charges with those plans on your behalf. Most health plans require us to collect payment they deem to be patient responsibility in the form of co-pays, deductibles, and co-insurance. We must also collect payment directly from the patient for services the plan does not cover. If MON does not participate with your insurance plan, payment-in-full is required at the time of service unless alternate payment arrangements have been made.

If your insurance ultimately denies responsibility for services you receive, you are responsible for payment. If you have a Health Savings Account (HSA), Health Reimbursement Account (HRA) or a Flexible Spending Account, we will provide all documentation necessary for you to receive appropriate reimbursement; however, payment is still required at time of service.

Uninsured Patients: Payment is due at the time services are provided. A minimum deposit of $100.00 - $300.00 (determined by the services anticipated) will be required prior to the appoinmtent. This payment will be applied to your total balance due upon check-out. Any overage will be refunded to you. If you are unable to pay your entire balance, an Account Specialist will assist you in establishing a payment plan.

Past Due Balances: Balances that are not paid within 30 days from the date of service are considered past-due. If your insurance company has not responded to our request for payment within 30 days, we will ask for your assistance in obtaining payment from the carrier and/or to make a payment on the balance. Balances that are not paid within 90 days of the date of service will be forwarded to a collection agency. Collection agency and any associated legal fees may be added to the account. Patients with past-due balances will be required to make payment arrangements before additional services will be scheduled.

No-Show and Late Cancellation Fees: Because cancelled appointment slots for surgeries, MRI and other procedures are difficult to fill without adequate notice, the following charges will be applied for appointments that are not cancelled at least 24 hours prior to the appointment time.
- MRI Appointments: $100.00
- Appointments for ESI (epidural steroid injection), EMG (electromyography), Tenex or surgical procedures: $150.00
Should be Empty:

	Have you tried any of the following for pain relief (check all that apply)?	Did this provide relief?	Name of Medication
Heat
Ice
Over the Counter Medications
Prescription

New Patient Packet

New Patient Information

Provider and Pharmacy Information

Insurance Information

Guarantor

Acknowledgement

General Medical Information

Medical History

Social History

Review of Systems

Clinical Function Score

HIPAA PRIVACY AUTHORIZATION

Consent Form

MIDLANDS ORTHOPAEDICS & NEUROSURGERY (MON) AUTHORIZATIONS AND ACKNOWLEDGEMENTS

Midlands Orthopedics & Neurosurgery, P.A. Financial Policy