New Patient Form

Patient Information
Name
Prefix First Middle Last Nickname
Date of Birth
Date Format: MM slash DD slash YYYY
Email
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Language
Marital Status
Gender
Self-Describe
(optional)
How Did You Hear About Us?
Home Phone
Ok to Leave a Message?
- Yes
- No
Cell Phone
Ok to Leave a Message?
- Yes
- No

Guarantor Information
Guarantor Name
First Last
- Self
- Other
Phone
Ok to Leave a Message?
- Yes
- No
Address
Same as Patient Address?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Date of Birth
Date Format: MM slash DD slash YYYY
Relationship to Patient

Emergency Contact
Emergency Contact Name
First Last
Relationship to Patient
Phone
Ok to Leave a Message?
- Yes
- No
Approved Individuals
Please list other individuals who we can communicate with regarding appointments and medical information.
Approved Individual Name
First Last
Relationship to Patient
Phone
Ok to Leave a Message?
- Yes
- No
- Add Another Individual
Approved Individual Name
First Last
Relationship to Patient
Phone
Ok to Leave a Message?
- Yes
- No

Insurance Information
Insurance Card
Drop files here or
Please upload an image of your insurance card
Self Pay?
- Yes
- No
Worker's Comp Case?
- Yes
- No
1. Insurance Company Name
- Primary
- Secondary
Policy ID#
Subscriber Name
Subscriber Relationship to Patient
Phone
Subscriber DOB
Date Format: MM slash DD slash YYYY
2. Insurance Company Name
- Primary
- Secondary
Policy ID#
Subscriber Name
Subscriber Relationship to Patient
Subscriber Phone
Subscriber DOB
Date Format: MM slash DD slash YYYY
Subscriber Social Security Number

Physical Therapy Information
Are you currently or have you recently worked with a physical and/or occupational therapist?
- Physical Therapist
- Occupational Therapist
Name of Physical Therapist
How Often?
Name of Occupational Therapist
How Often?
Additional Information
Have you received a like or similar device within the last 2-3 years from either Bulow Orthotic & Prosthetic Solutions or any other provider?
- Yes
- No
Are you currently residing in a nursing home, assisted living or group home?
- Yes
- No
Name of Facility
Phone Number of Facility
Have you received a motorized wheel chair through insurance?
- Yes
- No

Payment and Policy Agreement

Your insurance policy is a contract between you and your insurance company to help you meet medical expenses. Because benefits can vary greatly, it is not possible for Bulow Orthotic & Prosthetic Solutions to provide services on the basis that your insurance company will pay all charges.

Bulow Orthotic & Prosthetic Solutions can in no way guarantee coverage. Benefits are determined by your insurance plan at the time your claim is processed. All benefit calculations are only an estimate, based on information obtained from your insurance company. The actual Total Patient’s Responsibility may be different than what was previously estimated by Bulow Orthotic & Prosthetic Solutions.

To prevent any misunderstanding about medical insurance, we wish to point out that: (1) Payment for all medical services furnished are the responsibility of the patient; (2) Deductibles, co-payments, and/or other patient responsibility amounts are due at the time services are rendered; (3) For deductibles, co-insurance and non-covered custom-made devices fifty percent (50 %) of the balance is due at the casting appointment, with the balance due at the time of delivery; (4) Bulow Orthotic & Prosthetic Solutions will bill your insurance company as a courtesy to you; however, Bulow Orthotic & Prosthetic Solutions is not responsible for non-payment from the insurance company; (5) If, due to unforeseen circumstances, additional procedures and/or treatments are necessary beyond what has been previously approved, patients must make arrangements for payment; (6) Patients are expected to keep their accounts current while waiting for their insurance company to remit payment.

In consideration of The Company’s efforts to supply patients with products and/or services to the patient, the patient or guarantor agree that each of them is responsible for payment. Payments may be made by check, money order, Visa or MasterCard. A $20.00 fee will be assessed for any check returned for any reason.

NO REFUNDS will be given for the following items: CUSTOM MADE ITEMS, PROSTHETIC SUPPLIES (LINERS, SLEEVES, SOCKS), NONSTOCK, and SPECIAL ORDER ITEM. All other items will be reviewed on a case by case basis.
Patient Complaint Process

We are committed to ensuring you are completely satisfied with the services and care you receive at Bulow Orthotic & Prosthetic Solutions. However, if for any reason you wish to file a complaint, any staff member can assist you in this confidential matter. You will be asked to complete a “Patient Complaint Form” to assist us in understanding your complaint or concern fully. Once the form is received, a company representative will investigate the complaint thoroughly and take the necessary actions to satisfy your complaint.

I have read and agree with the Payment and Policy agreement. I also certify the information provided by me is true, accurate and complete to the best of my knowledge.
Patient / Parent / Guarantor Signature
Date
Date Format: MM slash DD slash YYYY
Patient / Parent / Guarantor Printed Name
*If the patient is 18 or older, the patient must sign
Relationship to Patient

Bulow Orthotic & Prosthetic Solutions Privacy Practices Acknowledgement, Consents, and Assignment of Benefits
Acknowledgement of Receipt of Notice of Privacy Practices and Company Policies

By signing below, I certify that Bulow Orthotic & Prosthetic Solutions, its parent company & its subsidiaries (“The Company”) has made available to me a Notice of Privacy Practices. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Bulow Orthotic & Prosthetic Solutions healthcare operations. The Notice of Privacy Practices also describes my rights and The Company’s duties with respect to my protected health information. Bulow Orthotic & Prosthetic Solutions reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, or asking for one at the time of my next appointment.
Consent for Contact

I, the undersigned, consent to be contacted by The Company by phone call, e-mail, US Postal Service or other means to follow-up on my care.
Use of Images

By signing below, I understand that Bulow Orthotics & Prosthetic Solutions may use my likeness in a photograph or video as part of its marketing efforts including but not limited to publication in external communication and social media posts. I waive the right to inspect or approve the finished product wherein my likeness occurs. Additionally, I waive any right to royalties or other compensation related to the use of those images.
Consent to Provide Services and/or Products

I understand that by signing this agreement, I indicate my wish to purchase orthotic and/or prosthetic products or services, or both, from The Company. I understand that I am under the supervision and care of my attending physician. I understand that my physician has prescribed the orthosis/prosthesis noted as part of my treatment. I also understand that due to the nature of the products supplied by The Company that they cannot be returned.
Assignment of Benefits

I, the undersigned, hereby authorize The Company to request on my/our behalf and to collect directly all public and private insurance benefits due for products and/or services supplied to me by The Company. In the event payments for insurance benefits are made directly to any of the undersigned, the payee will endorse to The Company all checks for such payments.
Consent to Coordinate Care and Release of Medical Records

By signing below, I authorize all medical personnel to provide information to The Company concerning my medical history, as it may relate to my treatment. This includes collecting medical information from any physician, surgeon, medical facility and/or physical therapist seen by me. The Company will comply with all HIPAA rules and regulations.
Patient Printed Name
Patient Date of Birth
Date Format: MM slash DD slash YYYY
Patient / Guardian Signature
Date
Date Format: MM slash DD slash YYYY
Guardian Printed Name (if applicable)
Guardian Relationship to Patient

Medical History Form
Diagnosis

Please list any past or current diagnos(e)s
Relevant Surgeries:
Medications
Comorbidities (check all that apply):
Other Comorbidity Description
Muscular Dystrophy Description
Identify All That Is True To Help Us Identify A Proper Treatment Plan
Strength / Mobility
Other Strength/Mobility Description
Work Details
My Job Is:
Living Situation
Relation to others I live with
Difficult Walking Conditions For Me Include
Other Walking Conditions Description
My Daily Activities Include
My Hobbies / Other Activities Include
Other hobbies / activities
Other Pertinent Information:
Patient / Guardian Print Name
Signature
Relationship to Patient

Heart Problems
Hypertenstion
Vascular Disease
Stroke
Diabetes
Kidney Disease
Osteoporosis
Hepatitis A, B, or C
Cerebral Palsy
HIV Positive
Rheumatoid Arthritis
Obesity
Osteoarthritis
Pulmonary Disease (TB)
Vision Problems
Parkinson Disease
Alzheimer Disease
Spina Bifida
Clubfoot
Pacemaker/Defibrillator
Seizure Disorder
Scoliosis/ Kyphosis
Currently Pregnant
MRSO/ VRE
Muscular Dystrophy:
Other:

Step 1 of 8

Patient Information

Guarantor Information

Emergency Contact

Approved Individuals

Insurance Information

Physical Therapy Information

Additional Information

Payment and Policy Agreement

Patient Complaint Process

I have read and agree with the Payment and Policy agreement. I also certify the information provided by me is true, accurate and complete to the best of my knowledge.

Bulow Orthotic & Prosthetic Solutions Privacy Practices Acknowledgement, Consents, and Assignment of Benefits

Medical History Form

Identify All That Is True To Help Us Identify A Proper Treatment Plan