Wilmington Orthotics & Prosthetics, Inc.

To better serve and make your visit to our office more efficient, you may complete and submit all the required patient information necessary for our staff to provide you with the quality of treatment you deserve. To print these forms instead, click here to return to our Patient Forms.

Please complete the fields below as thoroughly as possible. If the fields do NOT apply, enter N/A or None. For questions, contact us at (910) 395-5775.

Date:
Last Name:
First Name:
Middle Initial:
Mailing Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
E-Mail:
Date of Birth:
Sex:		Female Male
Diabetic:		Yes No
Social Security Number:
Height:
Weight:
Employment:
Employment Status:		Full Time Part Time
Marital Status:
Emergency Contact:
Relationship:
Contact Number:
Employer/School:
Employer/School Address:
Employer/School City:
Employer/School State:
Employer/School Zip:
Employer/School Phone:
Workers Compensation Manager:
Workers Compensation Phone:
Workers Compensation Fax:

Referring Physician:
Referring Physician Phone:
Primary Physician:
Primary Physician Phone:
Physical Therapist:
Physical Therapist Phone:
Diagnosis:
Reason for Visit:

		Have you had a similar item/service within the past year? Yes No
		Is your condition a result of an accident? Yes No
		If so, type of accident? Auto Work Other
Date of Injury:
Shoe Size: (diabetic ONLY)
		Please review the below questions and mark the appropriate button. Consent for Treatment I, the undersigned, hereby consent to treatment under the recommendations and instructions of the physician and/or therapist. I CONSENT NO CONSENT Release of Medical Record Information I authorize any holder of medical or other information about me to release such information as may be necessary for the completion of my insurance claims to Wilmington Orthotics & Prosthetics, Inc. This electronic submission is to be considered valid. I AUTHORIZE NO AUTHORIZATION Assignment of Insurance Benefits I hereby authorize direct payment to Wilmington Orthotics & Prosthetics, Inc. for my insurance benefits herein specified and otherwise payable to me. I also hereby authorize automated claims to be submitted electronically to Medicare on my behalf. I AUTHORIZE NO AUTHORIZATION Medicare Authorization I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I AUTHORIZE NO AUTHORIZATION Waiver of Liability or Guarantee of Account I understand I will be financially and legally responsible for charges not covered by this assignment. The undersigned further agrees to pay all costs of collection of any such balance, including responsible attorney's fees. I AGREE I DO NOT AGREE FOR MEDICARE RECIPIENTS: Medicare will ONLY pay for services that are determined to be "reasonable and necessary" under Section 1862 (a)(1) of the Medicare Law.
		Please click on the links below to review our Summary of Privacy Practices and HCFA Medicare Supplier Standards. Please be advised we will need to photocopy your insurance card, driver's license or ID, and prescription card (if applicable). Payment arrangements must be made before any service is provided for charges $100.00 or less. Payment is due upon services rendered unless otherwise arranged.
E-Signature: (Full Name)		By e-signing this submission, you are acknowledging the information provided within is true and accurate to the best of your knowledge. Your e-signature also acknowledges receipt and understanding of our Summary of Privacy Practices and the HCFA Medicare Supplier Standards. (Please be aware that from time to time, you may still be asked to sign an original authorization and/or consent form when visiting our office.)

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