Patient Intake Form — Kinetic O&P

Patient Information

Patient Name *

Date of Birth *

Address *

City *

State *

ZIP *

Cell Phone *

Home Phone

Emergency Contact Name *

Emergency Contact Phone *

Email *

Height *

Weight *

Diabetic *

Yes No

Primary Insurance

Primary Insurance *

Insurance Phone

Policy # *

Group #

Secondary Insurance

Insurance Phone

Policy #

Group #

Physician Information

Referring Physician *

Phone

Primary Physician

Phone

Diabetic Physician

Phone

Medical History

General Health *

Excellent Good Fair Poor

Tobacco Use

Yes No

Falls in the last 6 months?

Yes No

Hospital/ER/Urgent Care in last 6 months?

Yes No

Do you have an amputation?

Yes No

Accident from Employment?

Yes No

Auto Accident?

Yes No

Other Accident / Condition Since Birth?

Yes No

Accident Date

State

Description of Accident

Have you received a same or similar device in the past 5 years?

Yes No

If so, when?

From what company?

Reason for visit today *

Activities/Hobbies

Any other health issues we should know about?

Agreements & Signature

HIPAA / Release of Information

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, and the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. We encourage you to read it carefully and completely before signing this Consent.

Purpose of Consent: By signing this form, you consent for Kinetic O & P LTD to use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. This includes release of information from your physicians, therapists, and others involved in the care and treatment.

Warranty Policy

The products and/or services provided to you by Kinetic O & P LTD are subject to the conditions and limitations of the Kinetic O & P LTD Warranty Policy.

The warranty period for custom orthoses and prostheses is three months for workmanship and materials. Needed adjustments or repairs within the warranty period will be done at no charge. Within the warranty period, there will be a charge for adjustments or repairs that are a result of abuse, undue rough wear or physical changes of the wearer. If the device is altered by anyone other than Kinetic O & P LTD, the warranty does not apply. Componentry is warranted for a period of one year or for the period of time expressed by the manufacturer.

Failure to contact Kinetic O & P LTD about fitting problems, or other concerns, or non-use of the device does not absolve the patient from responsibility of payment. Since the device is custom fabricated and prescribed by your physician, it cannot be returned for credit on the account. Prescribed "off-the-shelf" items cannot be returned for hygienic reasons.

Assignment of Benefits

I authorize my insurance company to pay benefits directly to Kinetic O & P LTD. I understand my insurance company may not pay for services that are not a covered benefit or are not considered medically necessary. I also understand that there may be benefit limitations with no-fault carriers as deductibles and benefit maximums may apply. I agree to be financially responsible for all services provided by Kinetic O & P LTD.

I authorize Kinetic O & P LTD to leave messages on my cell phone / home phone and/or contact me by email.

Yes No

Printed Name (Patient or Representative) *

Relation to Patient (if representative)

Date *