Cascade Orthopedic Specialists New Patient Form

1813 W Harvard Ave, Ste 110 Roseburg, OR 97471

Patient's First Name*

Patient's Middle Name

Patient's Last Name*

Gender

Male

Female

Others

Date of Birth*

Marital Status

SS#*

Physical Address*

Mailing Address Same As Above*

Yes

No

Mailing Address*

Home Phone*

Work Phone

Primary Contact Number

Email

Pharmacy

By listing phone numbers above, you are authorizing the use of those numbers as a means to contact you.

Employer

Employer Phone

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Driver's License Number

State

Emergency Contact

Phone

Responsible Party / Guarantor (to whom statements are sent)

Same as Above?

Yes

No

Guarantor's Name

Date of Birth

Guarantor's Relationship to Patient

Guarantor's Address

Guarantor's Employer

Phone

Guarantor's SSN

Additional Doctors You See:

Primary Care

Other

What Are We Seeing You About?*

Date Of Injury?

Insurance Information:

(All Copays Are Due At The Time Of Check In.)

Patient Name*

DOB*

Primary Insurance

Insurance Name*

Member/Policy ID#*

Group#

Subscriber Name

DOB

Claims Address

Phone Number

Subscriber SSN

Effective Date

Secondary Insurance

Insurance Name

Member/Policy ID#

Group#

Subscriber Name

DOB

Claims Address

Phone Number

Subscriber SSN

Effective Date

Self-Pay

* (Self pay requires payment/deposit arrangements prior to appointment.)

Consent to Treatment and Authorization Cascade Orthopedic Specialties

The undersigned patient or authorized individual acting on behalf of the patient understands and agrees as follows:

Cary T. Sanders, M.D., Brandon Bishop DPM, Benjamin Baird PA-C as part of Cascade Orthopedic Specialists:

Reserve the right to designate any qualified physician to perform and administer care and treatment in his absence. This is to provide care on a continuous basis and especially in emergency situations. Dr. Sanders and Dr Bishop share the emergency, night, weekend and holiday call on a rotation basis with other qualified orthopedic surgeons and podiatrists.
Is granted permission to release to the insurance carrier and/or referring physician information in connection with treatment rendered to the patient on the patient's behalf in compliance with HIPAA guidelines. In work compensation cases the patient gives permission to release information to the workers compensation carrier in compliance with the industrial injury laws. If you do not desire this, please inform us in writing of your request. Your patient confidentiality is respected and vigorously protected. Our interest is in helping you obtain insurance benefits in a timely fashion.
The patient assigns all insurance benefits and authorizes direct payment to Cascade Orthopedic Specialists. I understand that I am financially responsible for all charges and that insurance is billed as a courtesy. It is understood in the event that the patient's insurance company does not make a payment or only a partial payment, the obligation remains. All co-pays and co-insurance are due at the time of service. Service is provided personally to the patient and not to the insurance company. Under no circumstances are services rendered on a contingency basis such as in accident claims or litigation.
I understand it is my responsibility to provide Cascade Orthopedic Specialists with accurate and current insurance information.

Patient Name*

Date

Phone: 541-391-8155 Fax: 541-391-8154
Cary Sanders, M.D.
Brandon Bishop DPM
Benjamin Baird, PA-C

Protected Health Information Disclosure Authorization

Patient Name*

Patient Date of Birth

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice reserves the right to change the privacy policy as allowed by law.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The practice may condition receipt of treatment upon execution of this consent
The practice may condition receipt of treatment upon execution of this consent.

May we phone, email or send a text to you to confirm appointments?*

Yes

No

May we leave a voicemail on your answering machine or cell phone?*

Yes

No

May we discuss your medical condition with any member of your family?*

Yes

No

How Did You Hear About Us?

Please complete the contact information below.*

Contact Name *

Relationship *

Phone *

If you are signing as the patient's guardian or legal power of attorney (documentation required)

Print Name

Describe Authority

Date

Phone

This field is for validation purposes and should be left unchanged.