Client Intake Form

General information

First Name

Last Name

Middle Initial

Date of Birth

Age

M/F

SSN (Optional)

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

A minimum of one telephone option is required

Email (Optional)

Who referred you to our office? (Optional)

Primary Physician

Phone

Referring Physician

Phone

Primary Insurance

ID Number

Secondary Insurance (Optional)

ID Number (Optional)

Location

Wilmington

Whiteville

Shallotte

Home

School/Daycare

Facility

A location is required

School/Facility

Phone

Contact

Title

Phone

Authorization of Payment

I request payment of authorized benefits of Medicare/ Medicaid or Private Insurance to be made to Atlantic Prosthetic Services, 1142 Shipyard Blvd. Wilmington, NC 28412 for any services rendered on my behalf. I authorize any holder of medical information about me, to release all information required for billing purposes. This authorization is valid for one year from signature date. I understand I will be responsible for any unpaid balance for services provided. I agree that I will be fully liable for all charges incurred by myself that my insurance company will not pay due to non-covered charges, deductibles, co-pays, non-allowed or any other reason. If I have any questions regarding this, I will speak with someone in the billing office.

Please check box and sign for information provided:

Patient Bill of Rights

Information Release Authorization

CMS Supplier Standards

HIPAA/Privacy Practices

Patient/Responsible Party Signature

Date

Personal Health Information

Patient Name

I understand that Atlantic Prosthetic Services (APS), may use or disclose my personal health information for the purpose of carrying out treatment, obtaining payment evaluating the quality of services provided and any administrative operations related to my treatment and/or payment. I understand APS will not share any of my information that is not completely necessary for the purpose it was intended. I understand I have the right to restrict how my personal health information is used and disclosed for treatment, payment and administrative operations if I notify the practice. I understand I have the right to revoke this consent by notifying APS in writing at any time. I also understand APS will consider requests for restriction on a case by case basis, but does not have to agree to requests for restriction.

I hereby consent to the use and disclosure of my personal health information for the purposes described in this notice.

ATLANTIC PROSTHETIC SERVICES HAS PERMISSION TO:

Leave a detailed message on your voicemail?

Yes

Contact via:

Text

Discuss your medical condition with? (List ALL that apply)

Yes

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Name

Relationship

Phone

Signed

Date

Photo Consent

Option 1

I, hereby grant and authorize Atlantic Prosthetic Services the right to take, edit, alter, copy, exhit publish, distribute and make use of any and all pictures or video taken of me to be used in and or for legally promotional materials, including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing.

I understand and agree that these materials shall become the property of Atlantic Prosthetic Services and will not be returned.

I hereby hold harmless, and release Atlantic Prosthetic Services from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.

If the person signing is under the age of consent, then this release must be signed by a parent or guardian, as follows:

I hereby certify that I am the parent or guardian of named above, and do hereby give my consent without reservation to foregoing on behalf of this individual

Option 2

I agree to option 1 but wish for content to be without my, or my child’s face, to be included.

Option 3

I do not consent to any of the above options and want to be excluded.

(Patient or Designee Signature)

Date

(Name of Designee and Relationship to Patient)

Consent to Medical Treatment of a Minor
(When Parent or Guardians is Not Present)

Patient Name

Date of Birth

I hereby state that I am the natural parent or legal guardian with legal custody of the above named minor and that I am authorized to consent to medical services on the minor’s behalf. l hereby authorize Atlantic Prosthetic Services and its associates, assistants or designees to examine and/or treat my child in my absence by the following designee.

Responsible Party

Relationship

SSN

Emergency Contact

Relationship

Phone

Individual(s) Designated to Consent to Medical Services:

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

I understand this consent to treatment is legal and binding until specifically revoked by myself or another person who has the legal right to sign or revoke this authorization.

Parent/Guardian Signature

Date

Printed Name

By checking this box, you agree to have your information electronically submitted to the entity named above

Client Intake Form

General information

Location

Authorization of Payment

Personal Health Information

ATLANTIC PROSTHETIC SERVICES HAS PERMISSION TO:

Photo Consent

Consent to Medical Treatment of a Minor (When Parent or Guardians is Not Present)

Individual(s) Designated to Consent to Medical Services:

Consent to Medical Treatment of a Minor
(When Parent or Guardians is Not Present)