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.

 

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
2013 OrthoSource Store Registration Form[...]
Microsoft Word document [164.0 KB]

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
Consent-To-Use-and-Disclosure-of-Health-[...]
Adobe Acrobat document [31.8 KB]
Notice of Health Information Practices
2013 Notice of Privacy Policy OS(1).doc
Microsoft Word document [34.5 KB]

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
Insurance-Verification-Form.pdf
Adobe Acrobat document [13.3 KB]

Special Promotion

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Contact Us

OrthoSource, Inc.
13839 Industrial Road
Omaha, NE 68137
(402) 408-0777

 

 

Contact Billing

402-408-0777

 

Or use our contact form.

Business Hours

Monday–Friday
8 a.m.–5 p.m. (CST)

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