Forms

Please use the following forms to help with your registration at OrthoSouce DME. The information under each heading will provide you with help in selecting which form to print and bring with you to your appointment.

Patient Registration Form

Complete all sections as appropriate. If the patient is 18 or younger, a parent or guardian is responsible for signing the consent for treatment section.

Patient Registration Form

Health Information Portability and Privacy Act (HIPPA) Form

The following documents outline the HIPPA Compliance Plan of OrthoSource DME. The Notice of Health Information Practice Policy is information that you can review as it applies to your situation. Please print the Consent to Use and Disclose form and bring it with you.

Consent to Use and Disclosure of Health Information

Notice of Health Information Practices

Patient Insurance Information Form

Please print this document and bring with you for your appointment. The information applies to the patient AND the primary insured as indicated on the card.

Insurance Verification Form