Unity Prosthetics and Orthotics
Patient Intake Form
Patient Intake Form
Patient Information
Date: ____________________________
Patient Name: First: __________________ Middle Initial: ______ Last: ________________________
Social Security #: ____________________________
Date of Birth: __________________ Gender: ☐ Male ☐ Female
Phone: _______________ Work: __________________ Cell: __________________
Email: ______________________________________________________
Address: __________________________________________________
City: _______________________ State: ______ Zip: __________
Responsible Party
☐ The responsible party is the patient listed above
☐ The responsible party is different than above
Full Name: ______________________________________________
Relationship: _______ ☐ Self ☐ Spouse ☐ Dependent ☐ Other: __________
Social Security #: ____________________________
Date of Birth: __________________________
Address: __________________________________________________
City: _______________________ State: ______ Zip: __________
Phone: ________________________________________________
Communication Preferences
May we phone, email, or text to confirm appointments or communicate about your care? ☐ Yes ☐ No
May we leave a message on your answering machine at home or cell phone? ☐ Yes ☐ No
May we discuss your medical condition with another person? ☐ Yes ☐ No
If YES, authorized person(s): ________________________________
☐ By checking this box, you authorize Unity Prosthetics and Orthotics to leave detailed phone messages, which may include protected health information, and to use email and text messaging for communication regarding your treatment plan, updates, and services.
Unity Prosthetics and Orthotics Patient Intake Form
Notice of Privacy Practices
This notice outlines your rights under the Health Insurance Portability and Accountability Act (HIPAA) and our responsibilities regarding your protected health information (PHI). By signing, you acknowledge receipt and understanding of this notice.
Your Rights:
Obtain a copy of your medical record: You may request an electronic or paper copy of your medical record. We will provide it within 30 days, with a possible reasonable, cost-based fee.
Request corrections: You may request corrections to inaccurate or incomplete health information. We may deny the request but will explain in writing within 60 days.
Request confidential communications: You may specify how we contact you (e.g., home phone, alternative address). We will accommodate reasonable requests.
Limit use or sharing: You may request we not use or share certain PHI for treatment, payment, or operations. We are not required to agree, but if we do, we will honor it. If you pay out-of-pocket in full, we will not share that information with your insurer unless required by law.
Obtain an accounting of disclosures: You may request a list of disclosures made in the past six years, excluding those for treatment, payment, or operations. One accounting per year is free; additional requests may incur a fee.
Obtain a copy of this notice: You may request a paper copy at any time.
Choose a representative: A person with medical power of attorney or legal guardianship may exercise your rights.
File a complaint: If you believe your rights are violated, contact us or the U.S. Department of Health and Human Services Office for Civil Rights (200 Independence Avenue, S.W., Washington, D.C. 20201, 1-877-696-6775, www.hhs.gov/ocr/privacy/hipaa/complaints/). We will not retaliate for filing a complaint.
Your Choices:
You may instruct us to share PHI with family, friends, or others involved in your care or in disaster relief situations. If you are unable to communicate your preference (e.g., if unconscious), we may share information in your best interest or to lessen a serious threat to health or safety.
We do not market, sell, or use your PHI for fundraising.
Our Uses and Disclosures: We may use or share your PHI to:
Treat you, sharing with other professionals as needed.
Run our practice, improve care, and contact you.
Unity Prosthetics and Orthotics
Patient Intake Form
Bill and obtain payment from health plans or entities.
Comply with public health, safety, research, or legal requirements (e.g., preventing disease, reporting adverse reactions, responding to lawsuits). For details, see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Our Responsibilities:
We must maintain the privacy and security of your PHI, notify you of breaches, and follow this notice.
We will not use or share your PHI beyond what is described unless authorized in writing. You may revoke consent in writing, but this will not affect prior disclosures.
We may change this notice, and updates will apply to all PHI. The new notice will be available in our office, on our website, or upon request.
Assignment of Benefits
I request that payment of authorized insurance benefits be made directly to Unity Prosthetics and Orthotics for services provided. I understand I am financially responsible for any balance not covered by insurance.
Medical Information Release Authorization
I authorize the release of medical information to Unity Prosthetics and Orthotics or its agents as needed to determine benefits or process claims.
Photo/Video/Scan Consent
I consent to being photographed, videotaped, or scanned for:
Clinical Documentation: For patient records, clinical evaluations, case studies, retroactive research, diagnosis, or fabrication, including release of related clinical notes from other disciplines (e.g., physical therapy, physicians).
Educational Purposes: For teaching or training rehabilitation professionals, potentially shared in portable electronic form with professionals treating similar conditions.
Promotional Purposes: For use in company brochures, our website, social media (e.g., Facebook, Instagram), or clinical partners' websites, with minimal identifiable information.
Financial Responsibility
I am responsible for any claim or portion not covered by insurance. If coverage is denied, I will assume payment responsibility. Payments for co-insurance and deductibles are due at the time of delivery.
Unity Prosthetics and Orthotics
Patient Intake Form
For custom items, full payment of co-insurance and deductible is required before ordering or fabrication. For prefabricated items, payment is due at fitting. Items are non-returnable and non-refundable once you leave the office, with free adjustments provided.
Unpaid balances for prior services must be cleared before new services. I must provide accurate primary and secondary insurance information at each appointment, or I will be responsible for all charges.
We will verify benefits and provide an estimate, but this is not a guarantee of payment. I will approve the estimate before the device is ordered, and payment is due upon approval.
Insurance authorizations may delay delivery. For out-of-network benefits, I am responsible for reasonable and customary charges. Workers' Compensation patients must provide claim information, or I will be responsible if the claim is controverted.
Returned checks incur a $35 fee. Unpaid balances may be sent to collections, with me liable for collection and legal fees.
Surplus payments may be applied to other accounts for which I am financially responsible, with any remaining balance refunded.
Medicare DMEPOS Supplier Standards
I acknowledge receipt of the Medicare Supplier Standards, available at http://www.ecfr.gov or in writing upon request, and understand that products/services are subject to these standards.
Verification of Information Accuracy
I verify that the information provided is accurate to the best of my knowledge.
Signature of Patient or Guardian: __________________________________
Printed Name of Patient/Guardian: ________________________________
Date: __________________________
Relationship to Patient: ______________________________________
Unity Prosthetics and Orthotics
Patient Intake Form
SMS / Text Messaging Consent
Patient Name: __________________________________________
Mobile Phone Number: ____________________________________
Text Message Consent
☐ By checking this box, you agree to receive conversations (external), conversations (between employees) messages from Unity Prosthetics and Orthotics. Reply STOP to opt-out; Reply HELP for support; Message & data rates mayapply; Messaging frequency may vary.
Visit https://www.unitypo.com/privacy-policy to see our privacy policy https://www.unitypo.com/sms-terms-conditions and for our Terms of Service.
Mobile information, including SMS opt-in data and consent, will not be shared with third parties or affiliates for marketing or promotional purposes. Information may be used as permitted or required for treatment, payment, health care operations, legal requirements, or to provide the communications requested by the patient.
Opt-Out and Help
To stop receiving text messages, reply STOP. After opting out, you will receive a confirmation that you have been unsubscribed and no further text messages will be sent unless you later opt in again. For assistance, reply HELP or contact Unity Prosthetics and Orthotics using the contact information provided by our office.
Acknowledgment
I understand that text messaging may have privacy and security risks. I understand that I may change my communication preference or withdraw my SMS consent at any time by notifying Unity Prosthetics and Orthotics or by replying STOP.
Patient/Guardian Signature: ____________________________ Date: ______________
Printed Name: ______________________________________
Relationship to Patient (if guardian): __________________________