SHASTA ORTHOPAEDICS & SPORTS MEDICINE PATIENT REGISTRATION

Patient Registration Form

Today's Date * +

Referred by: *

Primary Care Provider: *

Body Part: *

Have you been treated by Shasta Ortho in the past? *

Yes

No

Are you here for an injury? *

Yes

No

If yes, date injury occurred.

Did your injury occur on the job? *

Yes

No

Is your injury sports related? *

Yes

No

How did the injury occur?

If work related, employer at time of injury:

Claim number

Adjuster's name

Patient Information

First Name *

Middle Initial *

Last Name *

Date of Birth (MM/DD/YYYY) *

Age *

Social Security Number * 🛈

Gender at Birth *

Male

Female

Gender Identity *

Male

Female

Race *

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Other Race not listed above

Preferred Language *

English

Spanish

Other Language

Translator Required? *

Yes

No

Email Address *

Physical Address *

City *

State *

Zip Code *

Mailing Address (if different)

City

State

Zip Code

Cell Phone *

Landline

Work Phone

Occupation

Employer

GUARANTOR OR GUADIAN (Parent of minor child, spouse, or legal representative)

Relationship to Patient

If "other" please specify relationship

First Name

Middle Initial

Last Name

Date of Birth

Social Security Number 🛈

Physical Address - include city, state and zip code

Mailing Address (if different) - include city, state and zip code

Occupation

Employer

PATIENT NOTIFICATION DISCLOSURE OF OWNERSHIP

The physicians at Shasta Orthopaedics & Sports Medicine have a financial interest in the healthcare facilities listed below:

Liberty Physical Therapy & Sports Performance and Shasta Orthopaedics MRI: Paul E Schwartz, MD; Stephen P Ferraro, Jr, MD; J David Schillen, MD; Farzad H Sabet, MD; Tony L Chang, MD; Eric J Jenkinson, MD; Forrest R Monroe, MD; Jason D Nowak, DPM

Apogee Outpatient Surgery Center: Paul E Schwartz, MD; Stephen P Ferraro, Jr, MD, J David Schillen, MD; Farzad H Sabet, MD

Mercy Outpatient Surgery Center: Jason D Nowak, DPM, Garrett Strand, DPM

SHASTA ORTHOPAEDICS & SPORTS MEDICINE and LIBERTY PHYSICAL THERAPY FINANCIAL POLICIES

The clinical providers, fellows, physical therapists, and technical staff at Shasta Orthopaedics & Sports Medicine and Liberty Physical Therapy provide professional, medical, and radiology services and bill only for those services and supplies. Services rendered by the hospital, surgical center, radiologist, laboratory, pathologist, anesthesiologist, medical equipment supplier, in some instances the assisting surgeon, are billed separately to your insurance carrier.

Shasta Orthopaedics MRI provides the image capture (technical component), and as required, a local radiology group provides the report narrative based on the image findings. Accordingly, you will receive two bills for your MRI, one from Shasta Orthopaedics for the technical component, and another from the radiology group for rendering the report.

Medicare

Shasta Orthopaedics & Sports Medicine and Liberty Physical Therapy are Medicare participating providers and bill the Medicare allowance. Your secondary insurance will be billed if you provide that information. You are responsible for paying the amount not covered by your secondary insurance. You will receive a statement that details all charges and payment activity.

Partnership HealthPlan and Medi-Cal

Shasta Orthopaedics accepts the Partnership HealthPlan and Medi-Cal allowance. You will be responsible for paying only the amount determined by Medi-Cal to be your share of cost, which must be paid in full at the time the service is rendered. Liberty Physical Therapy currently does not accept Partnership HealthPlan and Medi-Cal coverage.

PPO Indemnity Insurance and HMO Plan

Prior to surgery you will receive an estimate of benefits (EOB), and all deductible, co-pay and co-insurance amounts will be due at that time. Actual benefits are determined when your bill is processed by the insurance carrier. You will receive a prompt refund should your payment exceed the actual cost; and you will be obligated to pay any balance owed. You will receive a statement detailing all charges and payment activity. In the event you and/or your insurance carrier does not pay within sixty-days of your surgery, Shasta Orthopaedics and Liberty Physical Therapy may be required to seek payment from you. Please assist with this process by notifying your insurance carrier to ensure their financial obligation is met.

Worker’s Compensation Insurance

Shasta Orthopaedics and Liberty Physical Therapy accept patients with worker’s compensation claims. You are required to provide accurate demographic information, including your social security number, injury, and employer. Prior to service we will obtain your claim number and pre-authorization from your worker’s compensation carrier. You will not receive a bill for services unless your claim is denied and determined not work related, whereupon your private insurance will be billed.

Uninsured

You will be responsible for paying in full for services rendered at the time of service. Please establish yourself as Cash Pay when you call to set your appointment. You will receive an estimate for the total cost of services and treatment.

Third Party & Liens

Shasta Orthopaedics & Sports Medicine and Liberty Physical Therapy do not accept third party or lien claims. You are responsible to pay for services rendered in full at the time of service. As a courtesy, Shasta Orthopaedics will provide you with a claim form to submit to your third-party payer.

Authorization to Release Information and Assignment of Insurance Benefits

Your signature on this form authorizes lifetime payment of insurance benefits to be made directly to Shasta Orthopaedics & Sports Medicine and assisting physicians for services rendered and authorizes the release of all information necessary to secure payment of benefits.

Medical Records and Forms

Notes from your visits with the provider can be downloaded at no charge from the online Patient Portal. Ask for assistance if you do not receive login information at the time of service. Copies of your medical records are available within 3 business days of receipt of a valid authorized request and require a cost-based production fee pursuant to HIPPA regulations.

Digital images can be copied and saved on a disk at your request. The charge for digital images is $15.00 per disk. Disks are usually processed and available within 24 hours upon receipt of payment. A request form is available at the front desk.

Shasta Orthopaedics & Sports Medicine and Liberty Physical Therapy may require a representative to complete insurance or disability forms on your behalf. The fee to complete forms is $5.00 per page; double-sided is considered two pages with a minimum charge of $15.00. Forms are processed within seven (7) business days upon receipt of payment. Additional fees will apply if copies are required.

Credit Card Processing Fee

Shasta Orthopaedics and Liberty Physical Therapy assess a 3.99% processing fee on payments made by credit or debit card. This fee is less than what the practice is charged for credit card payments.

Cancelled or Returned Checks, Non-Sufficient Funds

Shasta Orthopaedics and Liberty Physical Therapy will assess a fee of $25.00 for each non-sufficient fund transaction, canceled, or returned check. Please call the billing office at (800) 727-5662 if you have questions about the charges on your bill.

Canceled or Missed Appointments

Contact Shasta Orthopaedics (530) 246-2467 or Liberty Physical Therapy at (530) 319-4123 if you are unable to keep your appointment. Below is a list of appointment types subject to Canceled or Missed Appointment fees. Missed appointment fees are NOT billed to your insurance carrier.

IMMOBILIZATION DEVICE WARNING

As part of your treatment, you may be prescribed an immobilization device, such as (but not limited to) a brace, splint, cast, sling, etc. Immobilization devices compromise range of motion, impair movement, and may adversely affect reflex time. Your signature below acknowledges that doctors at Shasta Orthopaedics strongly advise against the operation of a motor vehicle or any power equipment while wearing an immobilization device, as this could result in injury or death. The doctors at Shasta Orthopaedics do not determine if it is safe to operate a motor vehicle while wearing an immobilization device. Legal determination of your ability to drive safely while wearing an immobilization device can be tested by an appropriately trained licensing authority, most typically the Department of Motor Vehicles.

PHYSICIAN PAYMENTS SUNSHINE ACT

As of 1/1/2023 all physicians must provide written notice to their patients about the Open Payments federal database, a tool used to search payments made by drug and device companies to physicians and teaching hospitals. Information can be found at https://openpaymentsdata.cms.gov. The act requires that detailed information about payment of value over ten dollars ($10) from manufacturers of drugs, medical devices and biologics to physicians and teaching hospitals be made to the public.

NOTICE OF PRIVACY PRACTICES

Protected health information (PHI) is information obtained and created by Shasta Orthopaedics & Sports Medicine and may include documentation of your symptoms, physical exam, test results, diagnosis, treatment, and treatment plans; including any documentation necessary to bill for services. The Notice of Privacy Practices explains federal HIPAA Privacy Rules for the protection and privacy of your PHI and details how Shasta Orthopaedics may legally use your health information. The Notice of Privacy Practices is posted on the wall in the waiting areas and a printed copy is available upon request. Additionally, the Notice of Privacy Practices is available for download from the Shasta Orthopaedics website at www.shastaortho.com. From the Shasta Orthopaedics Home page select: For Patients, Registration Forms, Learn More, Notice of Privacy Practices. If you have any questions about the HIPPA Privacy Rule or navigating the Shasta Orthopaedics website, please contact Gary Whiteaker at (530) 246-2467.

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF INSURANCE BENEFITS

My signature below acknowledges that I have read, understand, and agree to the following:

Disclosure of Physician Ownership - I do not object to utilizing healthcare services provided by the physicians at Shasta Orthopaedics & Sports Medicine who have financial interest in Liberty Physical Therapy, Apogee Outpatient Surgery Center, or Mercy Outpatient Surgery Center.
Authorization to release information and assignment of insurance benefits - I understand I am financially responsible for all charges whether covered by insurance or not. In the event of a default judgement, I agree to pay all costs of collection and reasonable attorney’s fees.
Use of anonymous images for educational/promotional purposes. I acknowledge and authorize SOSM to use deidentified, anonymous, diagnostic images such as x-ray, MRI, or CT scans, pictures and other images or likenesses in presentations for educational/promotional purposes.
Physician Payments Sunshine Act – I acknowledge receipt of information about the Open Payments Database.
Immobilization Device Warning – I acknowledge receipt of Immobilization Device Warning.
Medication History - I agree to allow my healthcare provider at Shasta Orthopaedics & Sports Medicine access to my medication history, including prescription information from all medical providers involved in my care.
Location, accessibility, and content of HIPPA Notice of Privacy Practices - I understand that Shasta Orthopaedics is permitted by federal privacy laws to make use of and disclose my health information for purposes of treatment, payment, and healthcare operations.
I agree that a photocopy of this agreement shall be as valid as the original.

I authorize representatives of Shasta Orthopaedics & Sports Medicine and Liberty Physical Therapy to leave messages on the following devices regarding test results, appointment information, billing questions, etc. *

Landline

Cell

Work number

Check this box if your health information is NOT to be released to anyone (except under the terms in the Notice of Privacy Practices).

My health information is NOT to be released to anyone (except as noted above).

I authorize representatives of Shasta Orthopaedics to discuss my health information with the following individuals:

	Name	Relationship	Phone Number
Contact 1	Name	Relationship	Phone Number
Contact 2	Name	Relationship	Phone Number
Contact 3	Name	Relationship	Phone Number

Check box if individuals entered above are for emergency contact only.

	Emergency Contact
Contact 1	Emergency Contact
Contact 2	Emergency Contact
Contact 3	Emergency Contact

Please complete and sign the form on the next page.

Signature of Patient or Legal Guardian if Patient is a Minor *

clear

Date *

Name of Patient or Legal Guardian (Type) *

Date *

Please complete and sign the form. It cannot be processed without all required fields.

7/30/2022