ORTHOPAEDIC SURGEONS DEEPLY ROOTED IN THE COMMUNITY
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Patient Forms - New Visit
The following forms will need to be completed for your first appointment.
In addition, you may print these forms off and complete them by hand and fax them to (316) 219-5899 or bring them with you for your first appointment. Patient Information
Patient Information Form to be filled out for your first visit to Orthopaedic & Sports Medicine
Patient Medical History
Patient Medical History Form to be filled out for your first visit to Orthopaedic & Sports Medicine
Billing Policy
Billing policy for HMOs, PPOs, and Managed Care Programs
HIPAA Privacy Form
Acknowledgement of Receipt of HIPAA Privacy Notice
Controlled Substance Medication Agreement
Controlled Substance Medication Agreement
Permission to Release Medical and/or Financial Information Form
Permission to Release Medical and/or Financial Information to A Specified Party
NOTE: Only patients over the age of eighteen are required to fill out this form. Consent to Treat Minors
Parents will complete this form in order for us to treat patients under the age of eighteen, when the parent or guardian is unable to attend the visit in person.
Medicare Secondary Payer Questionnaire
Complete this form only if you have Medicare as your Primary Insurance
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