Patient Info

Patient Information

In the case of an emergency please contact:

Health Insurance Info

Employer Information

Workman’s Comp/Motor Vehicle Related

If this is Workman’s Compensation case or Motor Vehicle accident please provide the following: Claim #, insurance carrier claims address, adjuster name and phone II, and date of the accident. Please provide before being seen by the doctor.

Orthopedic Patient Health History

Surgeries and hospitalizations

Today's Problem

Consent and Signature

Authorization for Health Info Disclosure

1. I authorize the RELEASE OF ANY INFORMATION concerning my health to any insurance company, attorney or adjuster as necessary to process any claim for payment to the above named medical provider’s charges incurred by me. I also authorize the insurance company to furnish the medical provider named above any information regarding my claims under the policy or Social Security Act.
2. In consideration of the above-named medical provider’s rendering of treatment to me without immediate compensation therefore I authorize and I IRREVOCABLY ASSIGN MY RIGHT TO PAYMENT of the above immediate named medical provider’s bill for treatment rendered to me out of the proceeds of any judgement or settlement in my case and furthermore, from any insurance company providing coverage to me for such expenses.
3. With reference to any contracted insurance providing coverage to me for the above medical provider’s treatment, I understand, authorize and agree that no payment due me under said contract of insurance shall be made to me for any other medical expenses until the above medical provider’s BILL FOR MY TREATMENT IS PAID IN FULL.
4. I give assignment and lien in any claims against a third party whose negligence may have caused my injury, up to the amount of the bill for treatment.
5. In the event any insurance company obligated by contractual agreement to make payment to me or to the physician, refuses to make such payment upon demand, I hereby IRREVOCABLY ASSIGN AND TRANSFER to the medical provider any CAUSE OF ACTION that exists in my favor against any such company, and I authorize the medical provider to prosecute that action either in my name or in his name and further to compromise, settle, or otherwise resolve said claim.
6. I waive the STATUE OF LIMITATIONS regarding my provider right to recover.
7. I permit a COPY OF THIS AUTHORIZATION to be used in place of the original.
8. I hereby appoint the above named medical provider and any of their duly authorized agents and employees to endorse any and all checks, drafts, or money orders which are made payable to the undersigned for medical service or the like which have been, or are to be performed by the medical provider.

YOU ARE INSTRUCTED TO PAY DIRECTLY TO THE ABOVE NAMED MEDICAL PROVIDER AT HIS OFFICE FOR ALL PROFESSIONAL SERVICES RENDERED TO ME BY HIS OFFICE. THIS INSTRUCTION TO YOU IS AN ASSIGNMENT OF MY RIGHTS UNDER THE MEDICAL COVERAGE OF THE INSURANCE POLICY OR MY RIGHTS UNDER THE THIRD PARTY LIABILITY CLAIM. ANY SUM OF MONEY PAID UNDER THIS ASSIGNMENT SHALL BE CREDITED TO MY ACCOUNT.

Our Financial Policy

We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies.

1. Payment is due at the time of service unless arrangements have been made in advance by your carrier. We accept credit cards as well as personal checks and cash.
2. Keep in mind that your insurance policy is a contract between you and the insurance carrier. As a service to you, we will file your insurance claim if You assign the benefits to High Mountain Orthopedics, which means the payment will be sent to High Mountain Orthopedics. If your insurance carrier does not pay the practice in a reasonable amount of time (60 days maximum), we will have to look to you For payment. If we later receive a payment from your insurance carrier, we will refund any overpayment to you.
3. We have made prior arrangements with many insurance companies and health plans to accept assignment on benefits. We will bill them directly, and you are responsible for any co-payment at the time to visit.
4. If you are insured by a plan that we do not participate with, we will prepare and mail the claim for you on an unassigned basis. This means that the insurance carrier may make the payment to you or refuse to make any payment. Therefore you are responsible for the full payment at the time of service.
5. Not all insurance plans cover all services. In the event your insurance plan determines a service is "not covered," you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.
6. We will bill your insurance company for all services provided in the office. You are responsible for any balance due.
7. If your account is referred for collection activity to an outside agency or attorney, because ot an unpaid balance remaining on my account, I hereby agree and promise to pay interest of 1.5% per month of the outstanding balance to be calculated staring from my last date of service. In addition, I also agree and promise to pay a collection fee of $100.00 or 33.33% of the total balance due, whichever is greater, upon placement with an attorney or collection agency because of an unpaid balance remaining on my account.
8. I provide authorization for High Mountain Orthopedics the right to appeal any claim denied or inappropriately paid on my behalf. I have read and understand the practice's financial policies and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.