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BASIC INFORMATION |
| Patient First Name |
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| Patient Last Name |
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| How do you prefer to be addressed? |
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| Email |
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| Date of Birth |
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| Sex |
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| Age |
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| Home Phone |
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| Cell Phone |
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| Home Address |
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| Home City |
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| Home State |
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| Home Zip |
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| Social Security Number |
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| Drivers License Number |
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| Marital Status |
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| Employer |
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| Occupation |
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| Nature of Business |
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| Employer Address |
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| Employer City |
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| Employer State |
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| Employer Zip |
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| Referred By |
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| Is Napa Valley Ortho your Primary
Care Doctor? |
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If no, name Primary Care Doctor
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| Emergency Contact Name |
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| Emergency Contact Phone |
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| May we leave a message at your
home with a person? |
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| May we leave a message at your
home on an answering machine? |
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| May we leave a message at your
work with a person? |
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| May we leave a message at your
work with a machine? |
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| Is this visit related to a Work
Injury? |
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If yes, Date of Work Injury:
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| Is this visit related to an accident? |
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| Is this visit related to an injury? |
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If yes to accident or injury, date
of accident or injury:
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| Briefly describe circumstances: |
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RESPONSIBLE PARTY IF OTHER THAN PATIENT: |
| Name |
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| Relationship to Patient |
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| Occupation |
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| Employer |
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| Home Address |
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| Home City |
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| Home State |
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| Home Zip |
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| Home Phone |
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| Work Phone |
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PRIMARY INSURANCE
INFO |
| Insurance Company |
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| Group Number |
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| Insurance Phone # (on card) |
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Subscriber Name
(person's name on card) |
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| Subscriber Date of Birth |
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| Subscriber Phone Number |
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| Subscriber Address |
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| Subscriber City |
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| Subscriber State |
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| Subscriber Zip |
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| Subscriber Relationship to Insured |
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SECONDARY
INSURANCE INFO (if any) |
| Insurance Company |
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| Group Number |
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| Insurance Phone # (on card) |
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Subscriber Name
(person's name on card) |
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| Subscriber Date of Birth |
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| Subscriber Phone Number |
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| Subscriber Address |
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| Subscriber City |
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| Subscriber State |
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| Subscriber Zip |
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| Subscriber Relationship to Insured |
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IF PATIENT IS A MINOR OR STUDENT (if any) |
| Mother's Name |
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| Mother's Occupation |
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| Mother's Employer |
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| Mother's Home Address |
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| Mother's Home City |
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| Mother's Home State |
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| Mother's Home Zip |
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| Mother's Home Phone |
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| Mother's Work Phone |
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| Father's Name |
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| Father's Occupation |
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| Father's Employer |
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| Father's Home Address |
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| Father's Home City |
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| Father's Home State |
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| Father's Home Zip |
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| Father's Home Phone |
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| Father's Work Phone |
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HIPPA |
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HEALTH INSURANCE PORTABILTY
AND ACCOUNTABILITY ACT (HIPAA)
NOTICE OF PRIVACY PRACTICES
I acknowledge that I have received a copy (5
pages) of the Napa Valley Orthopaedic Medical Group,
Inc. Notice of Privacy Practices. This Notice describes
how Napa Valley Orthopaedic Medical Group, Inc.
may use and disclose my protected health information,
certain restrictions on the use and disclosure of
my health care information, and rights I may have
regarding my protected health information.
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| Name: |
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| Date: |
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| Initials: |
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| I have been given an opportunity to take a copy of the Napa Valley Orthopaedic Medical Group, Inc. Notice of Privacy Practices to review and hereby voluntarily decline to take a copy for my own review. I have been made aware that Napa Valley Orthopaedic Medical Group, Inc. functions under the guidelines of the Health Insurance Portability and Accountability Act (HIPAA), but do not wish a hard copy of the policy at this time. |
| Name: |
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| Date: |
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| Initials: |
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CONSENT FOR
TREATMENT |
Adult
I hereby give Napa Valley Orthopaedic Medical Group, Inc., its physicians, and its medical staff my consent for any necessary medical evaluation and treatment.
OR
Complete for a Minor
I certify that I am a legal guardian of
, a minor, and I do hereby give Napa Valley Orthopaedic Medical Group, Inc., its physicians, and its medical staff my consent for any necessary medical evaluation and treatment.
INSURANCE ASSIGNMENT
I give permission to Napa Valley Orthopaedic Medical Group, Inc. to bill my insurance carrier for services rendered. I understand that this is a service provided by Napa Valley Orthopaedic Medical Group, Inc. I request that payment of authorized Medicare or other insurance company benefits be made directly to Napa Valley Orthopaedic Medical Group, Inc., otherwise payable to me, for any services furnished to me by Napa Valley Orthopaedic Medical Group, Inc. Regulations pertaining to Medicare assignment of benefits apply.
I permit a copy of this authorization to be used in place of the original. I understand that I must inform my physician if I know that a party other than Medicare is responsible for paying for my treatment.
I understand that I am responsible for my medical bills unless I have verified coverage under an active Worker’s Compensation claim. I hereby guarantee payment of all physician/provider charges and understand that any amount not paid by insurance within 60 days of service becomes my personal responsibility unless my injury is covered under an active Worker’s Compensation claim. Examples of this would include but not be limited to any coinsurance, deductibles, and copayments.
INFORMATION RELEASE
I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance, information needed for this or a related Medicare or other insurance company claim. I understand that my signature requests that payment be made and authorizes release of any medical or other information necessary to pay the claim.
PAYMENT POLICY
It has been explained to me that if I am paying privately for medical treatment, payment of all charges is to be made in full at the time of service unless previous arrangements have been made, and I agree to pay all the charges.
If there is a co-payment for the medical service, I understand that it is due at the time of service, and I agree to make this payment.
I have carefully read and agree to the above information. |
| Name: |
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| Date: |
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