AmPro Orthotics & Prosthetics, Inc. Patient Information Sheet Patient Name:________________________________________________Date of Birth:_____________________ SSN:__________________Gender: Male/Female_________Marital Status: Married/Single/Other  Ht:_____Wt____ Home Phone:_______________________Work Phone:_________________Cell Phone:____________________ Home Address:______________________________________________________________________________ City:________________________________State:_______________________Zip Code:____________________ Legally Responsible Representative (Parent or legal guardian) Name:______________________________________________________Date of Birth:_____________________ SSN:_____________________Relationship to Patient:_______________________________________________ Phone:__________________________Address:____________________________________________________ City:_______________________________________State:_________________Zip Code:___________________ Insurance Information Primary Insurance & Phone:____________________________________________________________________ Secondary Insurance & Phone:__________________________________________________________________ Referral Information Referring Physician & Phone:___________________________________________________________________ Primary Care Physician & Phone:________________________________________________________________ Diagnosis:__________________________________________________________________________________ If having surgery,date scheduled:________________________________________________________________ Work Comp Information Worker Comp Insurance & Phone:_______________________________________________________________ Date of Injury_______________________________________________________________________________ Employer name & Phone:______________________________________________________________________ Employer address:____________________________________________________________________________ City:________________________________________________State:______________Zip Code:_____________ Medicare Patients Is patient enrolled in a Medicare HMO Program?.....................................................................................YES       NO Was patient enrolled in a Medicare  HMO and returning to Medicare only?.............................................YES       NO Is patient employed?......YES      NO          If employed, does patient have employer health insurance?...YES     NO Employer Name, if employed:___________________________________________________________________ Is patients spouse employed?.............YES   NO          If yes, employer insurance with spouse?..................YES    NO Spouses Employer, if employed:_________________________________________________________________ Questions for Patient What item(s) is being requested?________________________________________________________________ Has the patient ever received the same or similar item?.........................................................................YES        NO If yes, what date was it received?________________________________________________________________ Is the item being replaced or repaired?.................YES       NO        If yes, what is wrong with the item?_______________________________________________________________ How did you hear about AmPro? Physician.....Phone book.....Senior Guide.....Friend/Relative.....Therapist.....Website.....Other:_________________ HIPPA I certify that I have received a copy of AmPro Orthotics & Prosthetics Notice of Privacy Practices (will be provided at time of check in) Initial   X___________________________________________________________________________________ Financial Copays and deductibles are due at the time the service or item is received.  Custom items require 50% of the copay or deductible to be paid upfront, prior to the item being fabricated.  The remaining 50% balance is due at the time of delivery.  Custom made items are not returnable.  Return Check fee is $20.00.  AmPro Orthotics & Prosthetics agrees to bill most health insurance providers if all necessary insurance information is provided.  If the insurance company does not pay for the item, the balance is the patients responsibility.  If the patients account is not paid by the insurance company within 45 days, the balance will become the patients responsibility. Initial  X____________________________________________________________________________________ Benefits, Medical Information Release Authorization, and Acknowledgement of financial responsibility I request my insurance benefits, if any, be paid directly to AmPro Orthotics & Prosthetics, Inc.  I authorize the release of any information necessary to AmPro Orthotics & Prosthetics, Inc to provide services or process claims.   As the responsible party, I understand that I am personally responsible for the entire amount of my claim and that insurance benefits may be limited of non-existent.  I agree to notify AmPro Orthotics & Prosthetics, Inc immediately of any change in insurance in insurance coverage or status.  I understand and agree that if it becomes necessary to forward my account to a collection agency, I will be help responsible for the cost of any such collection including, but not limited to, reasonable attorney's fees> Patient or responsible party signature:   X_________________________________________________________ Date:______________________________________________________________________________________