If you have secondary insurance, please list it below:

Assignment of Benefits:

•I understand I am financially responsible for all charges and services provided to me, including the balance remaining after payment of potential insurance benefits. I authorize payment of medical insurance benefits to The Orthopedic Center of St. louis for professional services rendered.

• I authorize the release of any information necessary to process this claim.

• I certify that all the above information is true and correct to the best of my knowledge. I give my permission to the Provider and/or medical staff to administer and perform such procedures deemed necessary in the diagnosis and/or treatment of my medical condition(s).

Work History:

Describe your job in detail (the job you were working when you developed the problem):

I authorize my physician and his/her employees, to provide the medical care, tests, procedures, medications, services and supplies considered advisable by my physician. These services may include pathology, radiology, emergency and other special services. In consenting to treatment, I have not relied on any statements as to results. In the event that any personnel assisting in the provision of care and treatment suffer inadvertent exposure to any of my blood and/or other bodily substance that are capable of transmitting disease and I am unable to consult timely with my physician prior to testing, I consent to limited testing to determine the presence, if any of antibodies to hepatitis A, B, and C and HIV.

STORAGE AND RELEASE OF INFORMATION
I consent to the electronic storage and transmission of patient health information. I hereby authorize my treating physician, to release by electronic means or otherwise any medical and/or billing information concerning my care, including copies of my medical records to:
a. Any governmental or other entity as required by law for purposes of reporting or for purposes of determining theeligibility in government sponsored benefit programs.
b .The supplier of any blood or blood products which may be administered to me for the purposes of quality controland recipient monitoring.
c. Any continuing care, residential or long‐term care facility, or home health agency for the purposes of providingservices for my care.
d. Another health care provider that prescribes medication electronically to provide continuity of care and qualityof care issues regarding prescriptions.
e. I also authorize my physician to obtain information from other providers regarding my care and treatmentincluding obtaining my electronic medication and prescription history from whatever source for the purpose of my continuing care and treatment.

To Release to:

 

Dr. Chris Reeves

14825 N Outer 40 Road, Suite 200

Chesterfield, MO 63017

 

Medical Records covering the periods of health care from

through

I authorize the providers and staff of The Orthopedic Center of St. Louis to discuss and disclose my Protected Health Information (PHI) to the person(s) named below.

Please list the name / relationship / phone number of the people you would like us to disclose your Protected Health Information to. (This allows us to speak with someone if they call in on your behalf. Example: family members, spouse, parents, or children.)

HIPAA: NOTICE OF PRIVACY PRACTICES

I have received, and/or been provided the opportunity to receive, a copy of the "Notice of Privacy Practices" that explains when, where and why my confidential health information may be used or shared.

I acknowledge that The Orthopedic Center of St. Louis physicians, medical assistants and other staff may use and share my confidential health information with others in order to 1) treat me, 2) to arrange for payment of my bill, and 3) for issues that concern The Orthopedic Center of St. Louis operations and responsibilities.

This authorization remains in force until revoked in writing. The purpose of this disclosure/use is for continued medical care.