Patient Registration

Patient Registration
Legal Name / Nombre Legal

First NameMiddle NameLast Name
Preferred Name / Nombre Preferido
Date of Birth / Fecha de Nacimiento

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender / Género
Phone Number / Número de teléfono
Format: (000) 000-0000.
Address / DIRECCIÓN

Street Address / DIRECCIÓN Postal

Street Address Line 2

City / CiudadState / Estado

Zip Code / Código Postal

Work Comp Claim Information

Información sobre reclamaciones de indemnización laboral
Workman's Compensation Insurance / Seguro de compensación Laboral:
Employer at time of injury / Empleador en el momento de la lesión:
Employers Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation / Ocupación:
Date of Injury / Fecha de la lesión:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Describe Injury / Describa la lesión.:
What body part/s are injured: Please list all and include which side / ¿Qué parte/s del cuerpo están lesionadas? (Enumere todas e incluya de qué lado) :
Have you injured this body part/s before / ¿Se ha lesionado esta parte del cuerpo?
If yes, please describe / En caso afirmativo, por favor, descríbalo.:
Have you had an MRI, MRA or CT? If so where?

Other
Adjuster Name / Nombre del ajustador:
Adjuster Phone Number / Número de teléfono del ajustador :
Format: (000) 000-0000.
Adjuster Email / Correo electrónico del ajustador:
example@example.com
Claim Number / número de reclamación:
Referring Physician or Location / Médica o clínica que lo refirio:
Please list treating physicians, therapists and treatment to date / Por favor, enumere a los médicos tratantes, los terapeutas y los tratamientos recibidos hasta la fecha.:

Consent to use or disclose Medical Information
I authorize Occupational Orthopedics, LLC to use and disclose of my health and medical information for the following purposes:
- Treatment: Use by our providers, staff, coordinating care with other medical providers, work compensation carrier and disability insurance companies
- Payment: Including authorization, scheduling, billing, payment, review for medical necessity, justification of charges, precertification and prior authorizations
- Healthcare Operation: Includes the usual administrative and business functions of our office
I understand that I have the right to revoke or restrict this consent provided that I do so in writing, except to the extent that Occupational Orthopedics, LLC has already used or disclosed the information in reliance to this consent.

I acknowledge, and hereby consent to such that the released information may contain:
alcohol use/abuse:   Initials
drug use/abuse:   Initials
psychiatric records:   Initials
HIV/AIDS testing, results or information:   Initials
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Patient Name:

First NameLast Name
Signature
Should be Empty:

Work Comp Claim Information