Referring Physician: Phone:
Primary Care Physician: Phone:
Please be sure to bring your insurance cards and photo ID to your appointment.
Primary Insurance: Policy #: Group #:
Subscriber Name (if dierent than patient):
Address: Phone:
Secondary Insurance: Policy #: Group #:
Subscriber Name (if dierent than patient):
Address: Phone:
I certify that the information provided by me is true, accurate and complete.
Signature of Patient/Guarantor: Date:
Mr Ms Mrs First: MI: Last:
DOB: Sex: Male Female Marital Status: Preferred Language:
Address: City: State: ZIP:
Primary Phone: Type: Cell Home Work Other: Email:
Emergency Contact: Relation to Patient: Spouse Child Other:
Contact Phone: Type: Cell Home Work Other:
Is patient also the guarantor? Yes No If yes, skip to PHYSICIAN INFORMATION.
Guarantor Name: Relation to Patient: Spouse Child Other:
Guarantor Phone: Address: City: State: ZIP:
Are you diabetic? Yes No If yes, provide the name and address of the physician treating your diabetes.
Physician Name: Phone:
Address: City: State: ZIP:
Have you received a similar service in the past 5 years? Yes No
Are you in hospice care? Yes No
Are you a resident of a skilled nursing facility (nursing home)? Yes No
Was your condition the result of an accident? Yes No If no, skip to INSURANCE INFORMATION.
Was your injury work related? Yes No If yes, provide employer at time of accident.
Employer Name: Date of Injury:
Address: City: State: ZIP:
Contact: Phone: Claim #:
Was your injury the result of an automobile accident? Yes No If no, skip to INSURANCE INFORMATION.
Insurance Adjuster Name: Phone: Claim #:
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Patient Name (please print clearly):
I understand that there are some circumstances that may require you to contact me regarding my care. By signing this form, I
authorize Hanger Clinic to contact me regarding appointments, treatment instructions, billing/account information or other matters
specific to my care. Please check which the following modes of communication Hanger Clinic may use to contact you:
How may we contact you (check all that apply)? Voice Messages Emails Text Messages
Phone: Work: Mobile/Text: Email**:
Revocation of authorization to contact me via email and/or text: I understand that I may revoke my consent for future
communications via email and/or text at any time by advising Hanger Clinic in writing. My revocation of authorization will not aect my
ability to obtain future health care nor will it cause the loss of any benefits to which I am otherwise entitled.
Authorization for disclosure of PHI: I authorize Hanger Clinic to share information regarding my treatment, or payment for treatment,
with the following individuals:
Name of spouse/partner: None
Name of other Individual: Relationship to Patient:
I request that payment of authorized Medicare, Medicaid, or private insurance benefits be made to Hanger Clinic or any of its
subsidiaries for any covered services furnished by Hanger Clinic. I agree to pay to Hanger Clinic the deductible and/or coinsurance
on my claim. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS)
and its agents, Champus / TRICARE and its agents, or to any private insurance company any information needed to determine these
benefits or the benefits payable for related services. Your signature below is an acknowledgment that you have received or been
given the opportunity to receive a copy of Hanger’s Notice of Privacy Practices.
Signature of Representative (acknowledging receipt only): Date:
Signature of Patient/Responsible Party: Date: Relationship to Patient:
Signature of Witness (if patient signing with a mark): Date:
Printed Name of Representative or Witness:
Patient Refused to Sign for Receipt of the NPP Patient is incapacitated
Other (please explain):
Reason for Patient’s Inability/Refusal to Sign***:
*Text Communications: I understand that text message charges from my mobile phone provider may apply. Please be advised that text communication is not always secure.
Text messages can be intercepted and, for this reason, we do not communicate personal health information through this method. I will ensure that I keep Hanger Clinic
informed of my up-to-date mobile number at all times or if the number is no longer in my possession. Note, texting is only used for appointment reminders and voluntary
survey participation requests.
**Email Communications: (Hanger Clinic utilizes encrypted email) In authorizing Hanger Clinic to communicate with me by email, I acknowledge that: (a) email is not a
secure medium for sending or receiving information and accordingly, there is a possibility that my emails may be read or otherwise accessed by a third party in transit (b)
although Hanger Clinic will make reasonable eorts to keep email communications confidential and secure, Hanger Clinic cannot assure or guaranty the confidentiality of
email communications; (c) in the discretion of Hanger Clinic, email communications may be made a part of my permanent medical record; and (d) email is not an appropriate
means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. Accordingly, I agree that I will not use email
to communicate regarding emergencies or other time-sensitive issues, or to communicate regarding other sensitive information. If I do not receive a response to my email
message within two (2) days, I agree I will use another means of communication to contact Hanger Clinic.
***Hanger made good faith eorts to obtain the above referenced individual’s written acknowledgment of receipt of the Notice of Privacy Practices
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