Welcome to the Patient Portal

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

What is the condition for which you are seeking medical attention?

Was injury/pain a result of an accident? YesNo

If yes: Job RelatedAutoOther:

Date of injury or onset:

Describe the events of the injury/accident/pain:

Have you previously been treated for this or a similar condition? If yes, what was the treatment?

What were the results of the treatment?

Have you had any diagnostic test related to condition (i.e. X-ray, MRI, CT, EMG)? YesNo

If yes, please list previous diagnostic tests.

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

Is there any other information you would like to share regarding your condition?

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

• Patient Name:
• Patient ID:
• Insured Name:
• Insured ID:

Street Address:

Apt / Floor #:

• City:
• State:
• Zip Code:

• Home Phone:
• Cell Phone:
• Work Phone:

Preferred Method Of Contact: Home PhoneCell PhoneWork PhoneEmail

Can we leave voicemail messages at your numbers: YesNo

Can we use your above email to send appointment reminders and other practice related information? : YesNo

Can we leave messages with members of your household: YesNo

• Occupation:
• Employer:

How did you hear about our practice?

• Primary Care Physician:
• Phone Number:

• Pharmacy Name:
• Phone Number:

Attorney Information (if applicable):

• Attorney Name:
• Phone:
• Fax:

Emergency Contact:

• Name:
• Relationship:
• Phone:

• Name:
• Relationship:
• Phone:

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

Primary Insurance Info

Name of Primary Insurance Company:

• Subscriber Name
• SS#
• DOB

Subscriber Employer

• Primary Insurance ID#
• Group #

Patients Relationship to Subscriber: SelfSpouseChildOther:

Secondary Insurance Info

Name of Secondary Insurance Company:

• Subscriber Name
• SS#
• DOB

Subscriber Employer

• Secondary Insurance ID#
• Secondary Group #

Patients Relationship to Subscriber: SelfSpouseChildOther:

Other Insurance:

Other Insurance Information: Worker's CompNo Fault

Date of Injury/ Accident:

Insurance Company Name:

Adjuster name & phone number:

Claim Number:

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

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

List any past surgeries you have had, including the year:

List any medications (with doses) you are currently taking:

Do you smoke? YesNo

If Yes, how many packs per day?

If Yes, how many years have you smoked?

List any allergies, and your reaction:

Are you allergic to latex? YesNo

What is the reaction? ItchingSwellingHivesAnaphylaxisOther

Please list any other relevant information not yet mentioned:

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

• Name:
• Date:

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

• Name:
• Relationship:

Phone Number:

• Name:
• Relationship:

Phone Number:

• Name:
• Relationship:

Phone Number:

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

• Patient Name
• Patient ID:
• Insured Name
• Insured ID

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