1. PATIENT INFORMATION

TODAY’S DATE:

2. PLEASE COMPLETE THIS SECTION IF SOMEONE OTHER THAN
PATIENT IS RESPONSIBLE FOR SERVICES

3. WORKER’S COMPENSATION

4. ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION

I, the undersigned, have insurance with and assign directly to Fountain Orthotics and Prosthetics, Inc. all medical benefits, if any, otherwise payable to me for service rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Fountain Orthotics and Prosthetics, Inc. to access/obtain/release any medical information/records on file necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

5. WAIVER FORM

I, understand that my eligibility for coverage by cannot be determined at this time. I wish to receive medical services from Fountain Orthotics and Prosthetics. If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment of all services provided.

Print Name
Signature of Insured/Guardian
Date

MEDICAL RECORDS RELEASE FORM

I authorize the release of my confidential health information by releasing a copy of my
medical records to
Fountain Orthotics & Prosthetics.

Patient Name :
Date of Birth:
Signature:
Date:

For Office Use Only

Fountain Orthotics & Prosthetics is requesting the following documents:

ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES

This form will be retained in your medical record

By my signature below I, , acknowledge that I received a copy of the Notice of Privacy Practices for Fountain Orthotics & Prosthetics, Inc.

I hereby designate the following individual(s) to receive communications from Fountain Orthotics & Prosthetics, Inc. that may include health information about me:

Name:
Relationship:
Phone:


If this acknowledgement is signed by a personal representative, complete the following:

Personal Representative’s name:
Relationship to Patient:

I authorize Fountain Orthotics and Prosthetics, Inc. to leave voice mail messages concerning my health information at the following number:


Patient Name (Printed)

Phone:

Date

Signature


Signature of Insured/Guardian

*This signature will be used to verify identity with regards to PHI (Protected Health Information)

For Office Use Only

I attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Employee Name

Date

Insurance Information

Fountain Orthotics and Prosthetics is requesting that you provide ALL insurance information and insurance cards at the time of service.

It is your responsibility to provide complete insurance information so that Fountain Orthotics and Prosthetics may bill your insurance(s) on your behalf. Failure to provide this information may result in you, and /or the member, being financially responsible for any and all outstanding balance(s) due.

Fountain Orthotics and Prosthetics is not responsible for any failure on your part to provide any and all correct and current insurance information. It is unlawful for Fountain Orthotics and Prosthetics to “back date” your date of service; therefore, it is imperative that you provide all necessary information no later than by your final fitting appointment.

Please understand that insurance companies base its decisions upon the dates of service as well as timely filing, so it is imperative that all insurance information is correct, current, up to date and complete. Thank you for your cooperation and assistance.

I fully understand and acknowledge the term and provisions regarding my responsibility as stated above.


Patient/Legal Guardian Signature

Date

Photo Release

Patient Name:
DOB:
Parent or Legal Guardian:

I consent to have MY (OR my child or an individual to whom I provide guardianship) image to be taken by the staff at Fountain Orthotics and Prosthetics as described below.

I understand that my (or child or an individual to whom I provide guardianship) photographs, videotapes, digital, and other images may be recorded to document and assist with my care and the payment of my bill (or child or an individual to whom I provide guardianship). These images may be used to assist in the education of students and residents within the institution. I understand that the Fountain Orthotics and Prosthetics will own these images, but that I will be allowed access to view them or to obtain copies of them at a reasonable cost. Other than for treatment, education, and payment purposes, images that identify me (or child or an individual to whom I provide guardianship) will be released and/or used outside the organization only upon written authorization from me or the patient representative.

I may revoke or withdraw this consent at any time. Such withdrawal of consent must be made in writing. Withdrawal of consent does not affect any information disclosed prior to the written notice of withdrawal.

I release and hold harmless Fountain Orthotics and Prosthetics and its staff and employees from any and all claims or causes of action that I may have of any nature whatsoever, which may in any manner result from the use of the photograph or other image.

By signing below, I am indicating that I have read and understand the “Consent for Photography” form. I am either the patient or have the authority to give consent for the patient. My questions regarding this consent have been answered.


Patient or Patient Representative Signature

Date

If Patient Representative, Relationship to Patient

Printed Name

Acknowledgement of Financial Responsibility Form

Provider:
Fountain Orthotics & Prosthetics

Member Acknowledgment of
Financial Responsibility

Member
Financial
Arrangement

This form is used for health insurance members who wish to receive healthcare services from Fountain Orthotics & Prosthetics that may not be covered by your health insurance benefit plan.

Your signature on this form acknowledges that you agree to bear full financial responsibility for all services provided as listed below:

  • The services that are not covered under your health insurance benefit plan, or,
  • the services that have not been otherwise approved for payment by your health insurance
  • INSURANCE IS NOT A GUARANTEE OF PAYMENT

Disclaimer

Insurance coverage is estimated – your actual indemnity may be more or less. You, the patient, are responsible for all amounts not covered by your insurance carrier. Year-ToDate used benefits and remaining deductible amounts are not affected until the procedure is completed and therefore are not used in this determination of benefits.

Fountain O & P charges two percent (2%) charge for all balances not paid within three (3) months.


Member or Member’s
Legal Representative Name (Please Print)

Member or Member’s
Legal Representative Signature

Date:

FOR QUESTIONS, CONTACT YOUR HEALTH INSURANCE MEMBER SERVICES AT THE NUMBER LOCATED ON YOUR HEALTH INSURANCE CARD.