NORTHERN COLORADO SURGICAL ASSOCIATES 2121 East Harmony Road Suite 250, Fort Collins, Colorado 80528
______(Circle one): M F Full legal name (Last, First, MI)
______Single Married Widowed Divorced Social security number Date of birth
______Mailing address (Street, City, State, ZIP)
______Home phone Work phone Cell phone Email address
Which phone number should be listed as primary? Home Work Cell
May we leave detailed health information on this voicemail? Yes No
______Primary Care Physician Referring physician (if different than PCP)
Emergency contact: ______Name Phone number Relationship to patient
If patient is under the age of 18, who is responsible for charges? ______Name Relationship to patient
PRIMARY INSURANCE: ______(Present card to front desk for scanning)
Who is the policy holder? Patient Other (please provide policy holder’s information)
______Policy holder’s full name/relationship to patient
______Address (Street, City, State, ZIP)
______Phone number
______Social security number (if known) Date of birth (if known)
SECONDARY INSURANCE: ______(Present card to front desk for scanning)
Who is the policy holder? Patient Other (please provide policy holder’s information)
______Policy holder’s full name/relationship to patient
______Address (Street, City, State, ZIP)
______Phone number
______Social security number (if known) Date of birth (if known)
1 CONSENT TO TREATMENT
I am a patient at Northern Colorado Surgical Associates (NCSA). By signing this form, I give my consent to be treated by the doctors of this practice.
RELEASE OF HEALTH INFORMATION
NCSA may release my health information to other doctors and staff who treat me. NCSA may release my health information to insurance companies NCSA may release my health information to companies that help NCSA improve the quality and cost of care provided to patients by reviewing the health care provided by the practice.
I hereby authorize NCSA to speak to the individual(s) named below regarding my care, my test results and my bill:
______Name Phone Relationship to patient
______Name Phone Relationship to patient
____ I do NOT want my information given to family or friends.
NOTICE OF PRIVACY PRACTICES
The Notice of Privacy Practices tells me my rights as a patient of NCSA. This includes how my medical records are protected by NCSA. This notice is posted in the waiting area of NCSA. Upon request, I may receive a printed copy of the notice.
FINANCIAL POLICIES
I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance and any other health plan to Northern Colorado Surgical Associates A photocopy of this assignment is to be considered as valid as an original.
I am responsible for providing proof of insurance coverage. I will inform NCSA of any changes to my insurance or demographic information. Regardless of insurance coverage, all charges are ultimately my financial responsibility. If my insurance requi9res a referral from my PCP to be seen at NCSA, it is my responsibility to see that this is completed. I am fully responsible for all charges no covered if a referral was not obtained. Co-pays are due at the time of service. It is my responsibility to understand my insurance benefits such as co-pays, deductibles and co-insurance. I understand I may be required to pay an estimated patient portion prior to surgery. If I do not have insurance, payment is due at the time of service unless other arrangements are approved by the office manager. If a payment arrangement is made on a balance due, I understand I must comply with that arrangement until the balance is paid in full. If my account becomes past due, NCSA may initiate the collections process. There is a $25 fee for any checks returned for non-sufficient funds.
PATIENT ACKNOWLEDGEMENT
I prove with my signature below that: The information I have given NCSA is correct, I have read and understand all of the information stated above, I have had a chance to ask questions about the information on this form, and All of my questions have been answered. I may withdraw this form at any time with a written request to NCSA.
______Print patient name
______Signature of responsible party Date
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