"Patient Intake Form - Orthopaedic Physicians of Colorado" - Colorado

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Orthopaedic Physicians of Colorado
Patient Full Legal Name
Previous Name
Please Print
First
Middle
Last
City
State
Zip
Address
Cell Phone
Work Phone
Ext
Home Phone
Sex: ___Male ___Female
Do you have a living will? ___Yes ___No
Date of Birth
E-mail address
Marital Status:
___Single ___Married ___Divorced ___Widowed ___Legally Separated ___Partner
Social Security Number
Employer Name and Address
Employment Status ___Full Time ___Part Time ___Not Employed ___Self Employed ___Retired ___Active Military ___Full Time Student ___ Part Time Student
Ethnicity ___Hispanic or Latino ___Non Hispanic or Latino ___Declined to provide information
Race ___American Indian or Alaska Native ___Asian ___Native Hawaiian or Other Pacific Islander ___Black or African American ___White ___Declined to provide information
Language ___English ___Spanish ___Indian ___Japanese ___Chinese ___Korean ___French ___German ___Russian ___Other:
Emergency Contact Name
Phone Number
Relationship
We require your primary care doctor or the referring doctor information. Most insurers require this information be included in your claim.
My Doctor is:
Phone Number
My Doctor's Address
City
State
Zip
My Pharmacy and location
Phone Number
Is the reason for your visit today due to an injury, fall or accident?
___No
___Yes If yes, be advised we cannot bill your insurance without the ACTUAL date of injury/fall/accident: _______/_____/_______
Type of injury/fall/accident? __Motor Vehicle __On the job injury ___ Other, please describe
I am the patient. I am the financially responsible party and/or insurance policyholder. Please continue to the Primary Insurance section below
I am a minor
Please complete the Responsible Party Information below
I am the patient but someone else is the policyholder for my insurance
Please complete the Responsible Party Information below
I am the patient, but a Power of Attorney relationship is in place
Please complete the Responsible Party Information below
Responsible Party Name:
First
MI
Last
Relationship
Responsible Party Date of Birth is
required
to enable us to file your insurance claim ______________/_________/__________
Responsible Party Social Security Number
-
-
Responsible Party Phone Number
Responsible Party Address
City
State
Zip
Responsible Party Employer
Responsible Party Work Phone Number
Please be prepared to provide your insurance card(s) and a photo ID to the receptionist upon your arrival for your appointment
Insurance Company Name
Insurance Company Phone
Full Legal Name of the Policyholder
Relationship to the Policyholder ___Self ___Spouse ___Child ___Other
Date of Birth of the Policyholder
Coverage Effective Date
Termination Date
Policy Number
Group Number
Copay Amount
Insurance Company Phone
Insurance Company Name
Full Legal Name of the Policyholder
Relationship to the Policyholder ___Self ___Spouse ___Child ___Other
Date of Birth of the Policyholder
Coverage Effective Date
Termination Date
Policy Number
Group Number
Copay Amount
If Medicare is your secondary insurance, why? ___Working Aged Beneficiary/Spouse ___Disabled Beneficiary under age ___ Other Liability
I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge.
Patient or Reponsible Party Signature
Relationship
Date
OPC Documents: Patient Demographics Rev - January 28, 2014
Orthopaedic Physicians of Colorado
Patient Full Legal Name
Previous Name
Please Print
First
Middle
Last
City
State
Zip
Address
Cell Phone
Work Phone
Ext
Home Phone
Sex: ___Male ___Female
Do you have a living will? ___Yes ___No
Date of Birth
E-mail address
Marital Status:
___Single ___Married ___Divorced ___Widowed ___Legally Separated ___Partner
Social Security Number
Employer Name and Address
Employment Status ___Full Time ___Part Time ___Not Employed ___Self Employed ___Retired ___Active Military ___Full Time Student ___ Part Time Student
Ethnicity ___Hispanic or Latino ___Non Hispanic or Latino ___Declined to provide information
Race ___American Indian or Alaska Native ___Asian ___Native Hawaiian or Other Pacific Islander ___Black or African American ___White ___Declined to provide information
Language ___English ___Spanish ___Indian ___Japanese ___Chinese ___Korean ___French ___German ___Russian ___Other:
Emergency Contact Name
Phone Number
Relationship
We require your primary care doctor or the referring doctor information. Most insurers require this information be included in your claim.
My Doctor is:
Phone Number
My Doctor's Address
City
State
Zip
My Pharmacy and location
Phone Number
Is the reason for your visit today due to an injury, fall or accident?
___No
___Yes If yes, be advised we cannot bill your insurance without the ACTUAL date of injury/fall/accident: _______/_____/_______
Type of injury/fall/accident? __Motor Vehicle __On the job injury ___ Other, please describe
I am the patient. I am the financially responsible party and/or insurance policyholder. Please continue to the Primary Insurance section below
I am a minor
Please complete the Responsible Party Information below
I am the patient but someone else is the policyholder for my insurance
Please complete the Responsible Party Information below
I am the patient, but a Power of Attorney relationship is in place
Please complete the Responsible Party Information below
Responsible Party Name:
First
MI
Last
Relationship
Responsible Party Date of Birth is
required
to enable us to file your insurance claim ______________/_________/__________
Responsible Party Social Security Number
-
-
Responsible Party Phone Number
Responsible Party Address
City
State
Zip
Responsible Party Employer
Responsible Party Work Phone Number
Please be prepared to provide your insurance card(s) and a photo ID to the receptionist upon your arrival for your appointment
Insurance Company Name
Insurance Company Phone
Full Legal Name of the Policyholder
Relationship to the Policyholder ___Self ___Spouse ___Child ___Other
Date of Birth of the Policyholder
Coverage Effective Date
Termination Date
Policy Number
Group Number
Copay Amount
Insurance Company Phone
Insurance Company Name
Full Legal Name of the Policyholder
Relationship to the Policyholder ___Self ___Spouse ___Child ___Other
Date of Birth of the Policyholder
Coverage Effective Date
Termination Date
Policy Number
Group Number
Copay Amount
If Medicare is your secondary insurance, why? ___Working Aged Beneficiary/Spouse ___Disabled Beneficiary under age ___ Other Liability
I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge.
Patient or Reponsible Party Signature
Relationship
Date
OPC Documents: Patient Demographics Rev - January 28, 2014