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Section A Forms:
Spears P and O
Spears Prosthetics & Orthotics/Rehab
Services, LLC
Patient Information Sheet
 Patient Name:
______________________________________________________________________
Address:
___________________________________
City:
______________ State: ___
Zip:
________
Home Phone:
__________________
Cell:
_________________
Work:
________________
Ext:
_____
Date of Birth:
__________________ Age: _____ Male: ___ Female: ___ Social Security
#:_____-____-_____
If Child, Parent or Legal
Guardian Name: _______________________________________________________
Marital Status:
Single___ Married___ Divorced___Widowed___ Spouse’s Name:
_______________________
E-mail:__________________________________________ Height: ________
Weight: __________
Primary
Insured’s Name:________________________ DOB:__________ SSN:____-____-_____
Employer Name:
_________________________ Employer Address: _________________________________
Emergency Contact:
_______________________ Phone #:_______________ Relationship: ______________
Are you
Diabetic?: Yes: ____ No: ____ Do you take Insulin? Yes: ____ No: ____
 Referring Physician:
_____________________________ Phone: ____________________________________
Diabetic
Physician: ______________________________ Phone:
____________________________________
Are you having or
have you recently had surgery? Yes: ___ No: ___ If so, what date?:
__________________
Surgeon Name:
_______________________________ Phone: _____________________________________
Primary Insurance:
______________________________ Phone #:______________________________________
ID#:_______________________________________________ Group
#:_________________________________
Secondary Insurance:
___________________________ Phone #:_______________________________________
ID#:_______________________________________________ Group
#:_________________________________
Workers Compensation?:
Yes: ___ No: ___ If yes, name of contact person: _______________________________
Phone #:
____________________________
Acknowledgement of Receipt of Notice of Privacy
Practices
SPEARS PROSTHETICS AND ORTHOTICS
I certify that I have received a copy of Spears
Prosthetics and Orthotics Notice of Privacy Practices. The Notice of Privacy
Practices describes the types of uses and disclosures of my protected health
information that might occur in my treatment, payment of my bills, or in the
performance of Spears Prosthetics and Orthotics health care operations.
The Notice of Privacy Practices also describes my rights and Spears
Prosthetics and Orthotics duties with respect to my protected health
information. The Notice of Privacy Practices is posted in front office lobby.
Spears Prosthetics and Orthotics reserves the right
to change the privacy practices that are described in the Notice of Privacy
Practices. I may obtain a revised Notice of Privacy Practices by calling the
office and requesting a revised copy be sent in the mail or asking for one at
the time of my next appointment.
____________________________________________________
Signature of Patient or Personal Representative
____________________________________________________
Print Name of Patient or Personal Representative
_____________________________
Date
____________________________________________________
Description of Personal Representative’s Authority
PATIENT SIGNATURE
DATE TIME
CONSENT TO TREATMENT: This is to certify that I, or my
Authorized Legal Representative, do hereby consent and authorize The
Company the administration and performance of all evaluative and/or
Prosthetic, Orthotic, or Pedorthic (O&P) devices which in the judgement of my
physician and/or O&P practitioner may be considered necessary or advisable as
a course of my treatment.
RELEASE OF INFORMATION: I authorize The Company and/or their assigns
to disclose any or all information in the medical record to any person,
corporation, or agency which is/may be liable for all or part of the charges,
or who may be responsible for determining the necessity, appropriateness,
amount, or other matter related to fees charged, including my insurance
company, its representative, an HMO, PPO, Workers Compensation carrier,
welfare funds, Medicare and/or Medicaid programs and/or their intermediaries
or carriers. I further authorize The Company to disclose such information to
its insurance carriers as may be necessary. All my past and present medical
records will be made available to any duly authorized person acting in any
capacity on behalf of The Company.
ASSIGNMENT OF INSURANCE BENEFITS: I authorize and request payment be
made directly to The Company for devices rendered to me for the purpose of my
treatment in this or any other facility or location. I understand that
insurance claims are filed as a courtesy, but I am solely and financially
responsible for charges, fees, and/or other debts incurred by me for treatment
and that I will aid The Company in their attempt to collect payment for
devices provided to me.
COVERED OR NON-COVERED CHARGES: I understand that some devices may
or may not be covered by my health insurance, and that some parts of the
devices may be covered and other parts of the same devices not covered as my
health insurance approves/applies coverage benefits. However, I agree and
understand that I am ultimately financially responsible for all charges,
whether “covered” or “non-covered” by my health insurance benefit plan. I
agree to pay The Company for all collection fees, court costs, and other
expenses involved in collecting any charges hereunder.
THE UNDERSIGNED CERTIFIES THAT HE/SHE HAS READ THIS DOCUMENT, IS THE
PATIENT, OR IS DULY AUTHORIZED BY THE PATIENT, TO EXECUTE THIS AGREEMENT AND
ACCEPTS ITS TERMS THEREOF, AND HAS RECEIVED A COPY OF THIS DOCUMENT.
PRINT PATIENT NAME ACCT NUMBER
CONDITIONS OF TREATMENT
PRESCRIBED SERVICES ONLY: The Company provide devices only by
physician referral and will only provide devices based upon a fully executed
prescription by a licensed physician.
WARRANTY CONDITIONS: The Company warrants that the physician’s
prescription and The Company’s professional good-faith interpretation of that
prescription will be strictly followed in providing this O&P device. Warranty
is provided in good faith only for fit and function as prescribed for a period
of 90 days. Warranty for fit and function is void if any changes or
alterations to the devices are performed by anyone other than by an
employee/authorized agent of The Company. Normal wear and tear and/or repairs,
as determined by a member of The Company’s professional staff, may not be
covered by this Warranty. No guarantee has been made or implied to me/the
patient as to the effectiveness, success or failure of the prescribed devices.
No one is authorized to abridge or amend this document other than the
President of The Company. Further, I agree to hold harmless, defend and
indemnify The Company against any and all liability, loss, or expense
whatsoever resulting from negligent or improper use of the devices provided.
PATIENT’S CERTIFICATION AUTHORIZATION: I certify, understand, and
agree by my signature below, or by the signature of my Authorized
Representative, that I am responsible for any health insurance deductible and
co-insurance amounts. I permit a copy of this authorization to be valid as the
original.
RIGHT TO CHOOSE: I understand that it is my right to choose the
provider of my O&P devices and I choose The Company as my provider of choice.
FOR MEDICARE BENEFICIARIES: Medicare regulations require that a
supplier must meet certain defined standards in order to provide services to
Medicare beneficiaries. These Supplier Standards will be provided to you. Your
signature, or the signature of your Authorized Representative indicates
receipt of the patient’s copy of this document, a copy of the Medicare
Supplier Standards, or The Company’s Medicare Beneficiary Complaint Resolution
Protocol. Signature below also grants permission to The Company to contact you
by telephone concerning your Medicare-covered devices.
FOR PROFESSIONAL SERVICES PROVIDED BY
SPEARS PROSTHETICS AND
ORTHOTICS/REHAB SERVICES, LLC
(Hereinafter referred to as “The Company”)
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