NEW PATIENT FORM

When coming to your first appointment, please bring your insurance card, photo identification, prescription (if you have it) and the prescribing physician’s contact information. Please fill out the form below. You may also download and print the form, click here.

PATIENT INFORMATION

Is your visit related to a work comp injury?	Email:	Date:
First Name:	Middle Initial:	Last Name:
Social Security #:	Date of Birth:	Gender:
Please select:	By selecting yes, you authorize WCBL to utilize email as a form of communication with you. Our communications only include information regarding your treatment plan, updates and our services. Your social security number will never be included in an email communication from us.
Phone #:	Cell #:	Work #:
Address:
City:	State:	Zip:
Please select:	By selecting yes, you authorize WCBL to leave detailed phone messages for you, which may include private healthcare information.

RESPONSIBLE PARTY

Select one:	Full Name:	Relationship:
SSN:	DOB:	Contact #:

EMERGENCY CONTACT

Full Name:

Phone #:

MEDICAL PROFESSIONALS INVOLVED IN YOUR CARE

Prescribing Physician:	Phone:
Primary Care Physician:	Phone:
Other:	Phone:

OTHER HEALTH CONDITIONS

Select all that apply.ArthritisOsteoporosisFibromyalgiaJoint PainMuscle PainVascular DiseasePrevious Heart AttackGoutStrokeChronic PainChronic Fatigue SyndromeAutoimmune DiseaseRheumatoid ArthritisObesityType 1 DiabetesType 2 DiabetesWound Heal DelayRespiratory DiseaseDepressionAnxietyMemory LossCancerParkinson’s DiseaseMultiple SclerosisSeizuresCerebral PalsyPost-PolioHIV/AIDSMRSAPregnancy
Previous Surgery(ies):	Other health conditions not listed above:

INSURANCE INFORMATION

Please bring your photo ID, insurance cards, and prescription to your appointment.
Primary Insurance:	Policy ID #:	Group #:
Policy Holder:	Policy Holder Name:	DOB:
SSN:
Secondary Insurance:	Policy ID:	Group:
Policy Holder:	Policy Holder Name:	DOB:

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

I,give permission to Westcoast Brace & Limb to release any information, verbally or written, on my behalf to the following persons. Please note that in order for WCBL to communicate to anyone other than the patient/guardian, that individual’s name must be listed to the right.
Name:	Phone:	Relationship:

CLINICAL PHOTOGRAPH RELEASE

I understand that Westcoast Brace & Limb may obtain a photograph of me for clinical purposes. This photograph of me will remain in my records and may be forwarded to my treating medical professional(s) (physician, nurse, therapist, and other medical professionals) for clinical purposes.
Parent/Guardian Signature:	Date:

How did you hear about Westcoast Brace & Limb?

Check all that apply:Medical ProfessionalHospital VisitInsuranceInternetPrint AdTelevisionAnother WCBL PatientMilitary Base/MAFBWCBLMailer/Postcard

BENEFITS, MEDICAL INFORMATION RELEASE AUTHORIZATION & ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY
I request my insurance benefits, if any, be paid directly to the provider. I authorize the release of any information necessary to provide services or process claims. As the responsible party, I understand that I am personally responsible for the entire amount of my claim and that insurance benefits may be limited or non-existent. I agree to notify Westcoast Brace & Limb of any change in insurance coverage of status.

LIFETIME MEDICARE B SIGNATURE & ASSIGNMENT OF/AND AUTHORIZATION TO PAY MEDICAL EXPENSE BENEFITS
I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration, to its’ intermediaries or carriers or billing agent of designated carrier, any information needed to this or a related claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party who accepts assignment.

If policy specifically prohibits assignment, I request a check be made payable to BOTH SUBSCRIBER AND ABOVE COMPANY and sent directly to the COMPANY. NOTE: Payment by an obligor to a person other than the assignee after notification of assignment may result in liability to the obligor to repay the amount paid.

SECONDARY INSURANCE AUTHORIZATION & ASSIGNMENT
I authorize payment of medical benefits to the party who accepts assignment.

RESPONSIBILITY
I understand that the entire amount of the fees for your services and/or Orthotic and Prosthetic devices is my personal responsibility even though this may or may not be covered by insurance. If you bill the insurance company directly, I understand that I am to pay my portion of the bill when your service is rendered. I further agree to personally pay within thirty (30) days any portion of the bill that is outstanding.

In the event this bill is turned over to a third party for collection, I agree to pay all reasonable collection fees including attorney and Court cost, plus 1.5 percent monthly charge on the outstanding balance.

Patient Signature:

Date:

WORKER'S COMPENSATION INFORMATION/THIRD PARTY LIABILITY

If your care involves a Worker's Compensation claim or third party liability, please complete the following information below:
Patient Name:	Employer (at time of injury):	Employer Phone:
Date of Injury:	State Injury Occurred:
Insurance Carrier Name:	Claim #:
Claims Adjuster Name:	Phone:

AUTO ACCIDENT / THIRD PARTY LIABILITY

Please check here if your injury was due to an auto accident.Please check here if your injury was due to third party liability (someone else is liable for your injury).Please check here if you have an attorney.Please check here if you have filed a lawsuit related to your injury.
Attorney Name:	Phone:

VERIFICATION OF INFORMATION ACCURACY

I verify that, to the best of my knowledge, the information I have provided in this online form is accurate.
Patient Signature:	Preferred WCBL location to be seen at.	Date: