Welcome to the Patient Portal

Save yourself time before you visit by completing the required patient forms before your appointment

Click the button below to get started. You will need to complete each form before you can proceed to the next form. If you are unsure of an answer, you can enter “I don’t know” or “N/A” (not applicable) and we will follow up during your visit.

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Purpose of Your Visit

Dr. Julie M. KellerDr. Stephen R. LindholmDr. Jesse W. Allert

YesNo

If yes: Job RelatedAutoOther:

YesNo

(Please give any reports/results of testing to receptionist)


**Please Note You Will Be Asked To Sign The Form When You Arrive For Your Visit

Patient Information

MarriedSingleDivorceSeparatedWidowed

Home PhoneCell PhoneWork PhoneEmail

YesNo

YesNo

YesNo

Attorney Information (if applicable):

Emergency Contact:


**Please Note You Will Be Asked To Sign The Form When You Arrive For Your Visit

Insurance Information

Primary Insurance Info

Patients Relationship to Subscriber: SelfSpouseChildOther:

Secondary Insurance Info

Patients Relationship to Subscriber: SelfSpouseChildOther:

Other Insurance:

Worker's CompNo Fault


**Please Note You Will Be Asked To Sign The Form When You Arrive For Your Visit

Notice of Privacy Practices

Restoration Orthopaedics keeps record of the healthcare services we provide you. You may ask to see and copy that record. You may also ask us to correct that record. We will not reveal your records to others unless you direct us to do so or unless the law authorizes or tells us to do so. You may see you record or get more information about it by contacting our office’s practice manager.

Acknowledgement of Receipt of Privacy Practice

I, received a copy of the Office's Notice of Privacy Practice.


**Please Note You Will Be Asked To Sign The Form When You Arrive For Your Visit

Personal Medical History

Do you have, or had: Family History Related surgeries/complications
Anemia Yes
Asthma Yes
Bleeding Disorders Yes
Bone Injury/Fracture Yes
Cancer Yes
Chronic Pain Yes
Diabetes Yes
Drug/Alcohol Abuse Yes
Epilepsy/seizures Yes
Gout Yes
Heart Arrhythmia or Murmur Yes
Heart Disease Yes
Heart Stents Yes
Hepatitis or Liver Disease Yes
High Blood Pressure Yes
High Cholesterol Yes
Joint Problems/Arthritis Yes
Kidney Disease Yes
Ligament/Tendon Injury Yes
Lung Disease Yes
Lyme Disease Yes
Nerve Problems Yes
Rheumatologic Disease Yes
Sickle Cell Anemia Yes
Thyroid disorders Yes
Tuberculosis Yes
Other: Yes

YesNo

YesNo

ItchingSwellingHivesAnaphylaxisOther


**Please Note You Will Be Asked To Sign The Form When You Arrive For Your Visit

HIPAA Compliant Authorization for the Release of Patient Information

Pursuant to 45 CFR 164.508

I authorize and request the disclosure of all protected information for the purpose of review and evaluation. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:

All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient and outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurse’s notes, social work records, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, statements, questionnaires/histories, correspondences, photographs, videotapes, telephone messages, and records received by other medical providers.

All physical, occupational and rehab requests, consultations and progress notes

All autopsy, laboratory, histology, cytology, pathology, records and specimens; radiology records and films; nerve conduction studies, EKG and cardiac catheterization results; videos/CDs/films/reports

All pharmacy/prescriptions records including NDC numbers and drug information

All billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment or denial of benefits

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, HIV/AIDS and alcohol or drug abuse. I authorize the release or disclosure of this type of information.

This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CRF 2.31, the restrictions of which have been specifically considered and expressly waived. You are authorized to release the above records to the following representatives:

Signatures





**Please Note You Will Be Asked To Sign The Form When You Arrive For Your Visit

Assignment of Benefits

LEGAL ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA AND OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND /OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE AND RELEASE OF MEDICAL AND PLAN DOCUMENTS

To (Insurance Company):

In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to the above named healthcare provider(s), as my designated Authorized Representative(s), all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such provider(s), regardless of such provider’s managed care network participation status. I understand and agree that I am legally responsible for any and all actual total charges expressly authorized by me regardless of any applicable insurance or benefit payments. I hereby authorize the above named provider(s) to release all medical information necessary to process my claims under HIPAA. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such provider(s) any and all plan documents, insurance policy and/or settlement information upon written request from such provider(s) in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions. I hereby convey to the above named provider(s), to the full extent permissible under the law, including but not limited to, any ERISA claim for benefits, breach of ERISA fiduciary duty, and ERISA claim for statutory penalties for failure to produce documents or information in accordance with ERISA §502(a)(1)(B), §502(a)(3) and §502(c)(1)(B), under any applicable employee group health plan(s), insurance policies or public policies, any benefit claim, liability or tort claim, chose in action, appropriate equitable relief, surcharge remedy or other right I may have to such group health plans, health insurance issuers or tortfeasor insurer(s), with respect to any and all medical expenses legally incurred as a result of the medical services I received from the named provider(s), and to the full extent permissible under the law to claim or lien such medical benefits, settlement, insurance reimbursement and any applicable remedies including, but not limited to, (1) obtaining information about the claim to the same extent as the assignor; (2) submitting evidence; (3) making statements about facts or law; (4) making any request, or giving, or receiving any notice about appeal proceedings; and (5) any administrative and judicial actions by such provider(s) to pursue such claim, chose in action or right against any liable party or employee group health plan(s), including, if necessary, bring suit by such provider(s) against any such liable party or employee group health plan in my name with derivative standing but at such provider(s) expenses. Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA, ERISA, Medicare and applicable federal or state laws. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, please advise and disclose to my providers / Restoration Orthopaedics in writing such anti-assignment provision within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and such anti-assignment is waived.

ADDENDUM TO PATIENT FINANCIAL RESPONIBILITY

To: Restoration Orthopaedics

I acknowledge the possibility that a check and/or checks may be sent directly to me instead of you, my provider. I understand this money is not mine even though the check may be written to me. I understand you are billing my insurance company as a courtesy to me but the money paid by the insurance company belongs entirely to you. I, therefore, agree to immediately, but certainly no later than 48 hours upon receipt of any such monies, forward this money directly to you. I will make no attempt to negotiate what portion I send to you. In any event, I acknowledge and agree that I am legally responsible for any charges for service rendered to me and I will pay all fees including any co-pays or deductibles, if applicable.

 

NOTE:   Please read the above agreements carefully and make sure that you understand all the terms and conditions before signing below. If you do not understand, please review contents with the staff prior to signing. Your signature confirms that you have read and fully understand all the agreements, terms, and conditions above. Agreed and Accepted by:


**Please Note You Will Be Asked To Sign The Form When You Arrive For Your Visit

Thank You! You’ve completed all the necessary patient forms for your appointment.