Patient Resources

If you are a new patient, please either download the form and email to [email protected], or fill in the form below. Please note that the Submit button will be disabled until all important information has been filled out. Please be sure to fill in all of the fields.

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Patient Registration

Please fill this form out if you are a new patient. All fields must be filled in in order to submit the form. The submit button will be disabled until you have entered all of the important information. Alternately, you can download the form and email to [email protected]

First Name*

Last Name*

Address*

Address Line 2

City*

State*

Please select

Please select
AL
AK
AR
AZ
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY

Postal Code*

Phone*

Guardian or Emergency Contact Name and Phone Number*

Email*

Date of Birth*

Male/Female*

Male

Female

Height*

Weight*

Insurance Information

Insurance Name*

Insurance ID #*

Group # (if applicable)

Secondary Insurance Information (If applicable)

Secondary Insurance Name

Secondary Insurance ID #

Secondary Group # (if applicable)

Physician Information

Physician Name*

Physician Phone*

HIPAA

• Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, and the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. We encourage you to read it carefully and completely before signing this Consent. • Purpose of Consent: By signing this form, you consent for KINETIC O & P to use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations

I have read, understood, and hereby agree to all of the terms stated above.**

Agree

Communication Authorization

I authorize KINETIC O & P to leave messages OR TEXT on my home phone, cell phone, or contact me by e-mail.

I have read, understood, and hereby agree to all of the terms stated above.**

Agree

Medicare Supplier Standards

"The products and/or services provided to you by KINETIC O & P are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained at http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards."

I have read, understood, and hereby agree to all of the terms stated above.**

Agree

Assignment of Benefits

I authorize my insurance company to pay benefits directly to KINETIC O & P. I understand my insurance company may not pay for services that are not a covered benefit or are not considered medically necessary. I also understand that there may be benefit limitations with no-fault carriers as deductibles and benefit maximums may apply. I agree to be financially responsible for all services provided by KINETIC O & P.

I have read, understood, and hereby agree to all of the terms stated above.**

Agree

Signature*

Date*