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Orthopaedic Associates of
Central New York
Patient Registration Form (1/07)
For problems not
associated with work/car injuries (i.e.- non-COMP, non- No-fault), fill out top table:
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Name: Last -
First -
Middle Initial -
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Date of Birth:
Age:
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SS#:
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Male Female
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Home Address:
Apt#
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City:
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State:
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Zip
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Phone#:
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College Address:
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Emergency
Contact:
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Relationship:
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Phone#:
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Person
responsible for bill:
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Phone#:
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Who may we thank
for this referral:
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Address:
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Phone#:
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Family Physician
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Address:
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Phone#:
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Fill out if Patient is an Adult
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Occupation:
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Employer:
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Employers
Address:
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Phone#:
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Spouse:
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SS#:
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Date of Birth:
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Spouse’s
Employer:
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Phone#:
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Fill out if Patient is a Youth or Student
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Father:
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Date of Birth:
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SS#:
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Address if other
than above:
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Phone#:
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Father’s
Employer:
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Work#:
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Mother:
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Date of Birth:
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SS#:
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Address if other
than above:
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Phone#:
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Mother’s
Employer:
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Work#:
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Insurance
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Primary
Insurance:
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ID#:
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Group:
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Subscriber:
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Secondary
Insurance:
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ID#:
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Group:
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Subscriber:
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Attorney if
liability:
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Phone:
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Address:
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PATIENT IS
RESPONSIBLE FOR ALL LIABILITY CLAIMS AND ARE REQUIRED TO PAY AT THE TIME
SERVICES ARE RENDERED.
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I authorize
release of medical information necessary to process claims and authorize
payment of medical benefits to Drs. Raphael, Nancollas, Eckhardt, Jones
Melfi, Wnorowski and DiStefano. I
authorize release of medical information to my referring physician.
Signed: Date:
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Orthopaedic Associates of
Central New York:
For Workers Compensation/No Fault Only:
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Name:
Last-
First-
Middle Initial-
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Date
of Birth:
Age:
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SS#
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Male/Female
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Address:
Apt:
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City:
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State:
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Zip
Code:
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Phone#:
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Occupation:
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Employer:
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Phone#:
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Employer
Address:
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Phone#:
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Emergency
Contact:
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Phone#:
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Spouse
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SS#
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Phone#:
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Who
May we thank for this referral?
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Address:
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Phone#:
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Family
Physician:
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Address:
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Phone#:
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Attorney:
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Address:
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Phone#:
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WORKERS’ COMPENSATION INFORMATION
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Injury
#1 Insurance Carrier:
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Date
of Injury:
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Address:
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Phone#:
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WCB#:
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Carrier
Case#:
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Area
Injured:
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Employer
at the time of Injury:
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Address:
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Phone#:
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Injury
#2 Insurance Carrier:
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Date
of Injury:
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Address:
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Phone#:
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WCB#:
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Carrier
Case#
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Area
Injured:
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Employer
at the time of Injury:
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Address:
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Phone#:
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NO FAULT (AUTOMOBILE) INFORMATION
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Insurance
Carrier:
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Address:
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Phone#:
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Date
of Accident:
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Area
Injured:
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Policy#:
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I authorize
release of medical information necessary to process claims and authorize
payment of medical benefits to Drs. Raphael, Nancollas, Eckhardt, Jones
Melfi, Wnorowski and DiStefano. I
authorize release of medical information to my referring physician.
Signed:
Date:
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PATIENT AGREEMENT
FOR FINANCIAL RESPONSIBILITY (MUST FILL OUT THIS AS WELL):
Due to the varied requirements of insurance companies
some services and items may not be covered by your
insurance program.
By signing this agreement you (the patient) acknowledge that you are
assuming ALL
financial
responsibility for charges associated with your visits, (including charges for
x-ray and durable medical
equipment) not covered by the insurance (s)
noted below.
Additionally, if your insurance requires a specialist
referral for your care, you (the patient) are responsible for
verifying that
your Primary Care Physician has completed the referral.
If the requirements of you insurance
plan have NOT been met, you
(the patient) assume ALL financial responsibility for those charges.
Insurance:
____________________________________________________
Patient Identification #:
_________________________________________
Patient Signature: _________________________________
Date: ________________
(Parent/Guardian if patient is a child)
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