Patient Registration

Insurance Guarantor

Emergency Contact

1. Consent for Treatment- I consent to necessary treatment, including medications, prescriptions, performance and operation of X-ray, or other studies that may be used by the physician, nurse, scribe, or staff.
2. Consent for E-Prescribing- I have been made aware and understand that the medical practices and offices may use an electric prescription systemwhich allows prescriptions and related information to be electronically sent between my providers and my pharmacy. I have been informed and understand that my providers using the electronic prescribing system will be able to see information about medications I am already taking, including those prescribed by other providers. I give my consent to my providers to see this protected health information.
3. Insurance- I understand this office participates in most insurance plans, including Medicare. I acknowledge that if I am not insured by a plan that thisoffice does business with, that payment in full is expected at each visit. I agree to provide to provide this office with my current insurance information.If I am insured with a plan that this office does business with, I will need to have a current card so that my coverage can be verified. There may be certain routine services performed during your visit(s), such as ultrasounds, X-rays, MRI, lab work, injections and/or other testing we feel is necessary for your treatment but may not be covered by your insurance contract. Knowing your insurance benefits is your responsibility. Please contact yourinsurance company with any questions you have regarding your coverage. By signing below, I agree that I will be responsible for costs not covered by insurance and for any costs not paid for by my insurance company, whether or not said costs are covered by my insurance contract.
4. Co-payments and Deductibles- I acknowledge that all co-payments and deductibles must be paid at the time of service, as required by my contract with my insurance company.
5. Cancellation/No-Show Policy- I understand and acknowledge that if I do not call to cancel an appointment, I may be preventing another patient fromgetting much needed treatment. Conversely, the situation may arise where another patient fails to cancel, and the office is unable to schedule me fora visit due to a seemingly “full” appointment book. If an appointment is not cancelled at least 24 hours in advance I agree to pay a $25 fee; this will notbe covered by your insurance company. If I am 15 minutes or more late for my scheduled appointment, I may be considered to have canceled my appointment without notice.
6. Notice of Privacy Practices- I acknowledge that I received a copy of the notice of Privacy Practices.

At OrthoSports1st, P.C. d/b/a OS1 Sports Injury Clinic (“OS1”), as described in the Notice of Privacy Practices, it is our policy to not release confidential health information except as specifically permitted (or required) by Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) (for example, for treatment, payment, and operations) or in accordance with a patient’s authorization. Please refer to the Notice of Privacy Practices for more information.

If you would like to authorize OS1 to release your protected health information (PHI) beyond what is already specifically permitted by HIPAA, please indicate the PHI you authorize to disclose and the individual(s) or organization(s), or class of individual(s) (e.g., coach or athletic trainers at my school) to whom you authorize OS1 to release such PHI:

➔ The disclosure will be made to the following (list the names or describe the class of individual(s)/organization(s)):

OR

I hereby authorize the use or disclosure of information about the above-named patient, and I understand and agree that:

1. I may refuse to sign this authorization, and treatment or payment will not be conditioned on whether I sign this authorization.
2. I have the right to revoke this authorization at any time in writing delivered to the OS1 address listed above.
3. Any revocation will be effective only to the extent that action has not been taken in reliance on my prior authorization. Unless Irevoke this authorization, it will expire in one (1) year.
4. The health information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient.
5. If OS1 has information relating to behavioral or mental health services, alcohol and drug treatment, sexually transmitted disease,AIDS, or HIV, this authorization would include such information unless I specifically indicate otherwise on this form.
6. Regardless of whether I sign this authorization, unless I specifically request a restriction on the information OS1 can use or discloseand OS1 agrees to such request, OS1 will still be permitted to use or disclose my protected health information as specificallypermitted by HIPAA (for example, for treatment, payment, and operations).
7. I have received a copy of this authorization.

If you have any questions or concerns, please contact OS1 Sports Injury Clinic’s Privacy Officer:
Chip Vance | 1031 Brock Gap Parkway, Suite 185, Hoover, AL 35244 | (205) 352-2911 | chip@bettersooner.com

1031 Brock's Gap Parkway, Suite 185
Hoover, AL 35244

Credit Card Payment Authorization Form

Schedule your account balance to be automatically charged to your credit card.

Automatic Payments Will Make Your Life Easier:

• It’s convenient (saving you time and postage)
• Your payment is always on time (even if you’re out of town), eliminating late charges

Here’s How Automatic Payments Work:

With authorization, your card will be charged with the insurance adjusted remaining balance.  Should your balance be more than $250, we will contact you to inform you and to possibly set up a payment plan if you wish.

Please complete the information below:

I authorize OS1 Sports Injury Clinic to charge the credit card indicated in this authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.

*If you prefer not to fill out this Credit Card Authorization form, please click Send Patient Registration Form below and leave this section blank.