SOUTHERN ARIZONA ORTHOPEDICS, P.C. PATIENT INFORMATION RECORD R. Wayne Wood, M.D., R. Mark Blew, M.D., Robert C.

Kersey, M.D., Timothy B. Dixon, M.D., Jerome K. Steck, DPM, George R. Bradbury, III, M.D.
Please print Patient ________________________________________________________Date of Birth_____/_____/_____Age______
Last First Middle

Address ________________________________________________________ Pager or Cell Phone (_____) _____-_____

Street

City______________________________ State_________ Zip Code___________ Phone (_______) _______-_________ Employer ________________________________Occupation_________________Phone (_______) _______-_________
Social Security # ________-______-________ Male___Female___Marital

Status: Married Single-Divorced-Widowed

Spouses Name _______________________________________________________________Date of Birth _______/______/______

Social Security # ______-_____-______ Employer _________________________Phone (_______) _______-_________ Nearest relative not living with you _____________________________________ Phone (_______) _______-_________
Name Relationship

INSURANCE INFORMATION: Primary Insurance ___________________________________________Policy#_______________ Group#____________ Policyholders Name _________________________________________DOB___________________________________ Secondary Insurance____________________________________Policy#_____________________Group#____________ Policyholders Name _________________________________________DOB___________________________________ OTHER INFORMATION: Reason for visit ___________________________________________Right Side___Left Side____Date of Injury_______ Who is your Primary care doctor?________________________________________________(_____)_____-_________
Name city Telephone

Who referred you to our office? ________________________________________________________________________ Have you executed an advanced directive declaration (LIVING WILL)? If yes, have you provided us with a copy? Yes_____No_____ Yes_____No_____

OUR OFFICE POLICY REQUIRES PAYMENT IN FULL AT THE TIME OF YOUR OFFICE VISIT, ULESS PREVIOUS ARRANGEMENTS HAVE BEEN MADE.

SIGNATURE (responsible party of spouse) ____________________________________Date______________________

Authorization for Telephone Communication between Southern Arizona Orthopedics and Patients Communication between Southern Arizona Orthopedics and our patients is vital to the function of our practice. Our office staff may need to contact you to perform functions, including: scheduling appointments, reminder calls for upcoming appointments, scheduling surgery, discussing billing, etc. Our office also understands that patients have a right to privacy regarding communication from our office. --------------------------------------------------------------------Southern Arizona Orthopedics required a means to contact you and to leave messages for you. Our policy is to contact you and to leave messages for you at your home or cellular phone for your privacy. I hereby authorize Southern Arizona Orthopedics to contact me and leave a message for me at Yes No Home telephone/ voice mail Number # ____________________________ Leave a message with a relative at home Cellular telephone/ voice mail Number # ____________________________ Our office staff may need to contact you during the day. We request authorization to contact you at your workplace. I hereby authorize Southern Arizona Orthopedics to contact me and leave a message for me at Yes No Work telephone/ voice mail Number # ____________________________ Leave a message with secretary Please contact (Name/Relationship) __________________________________________________ In an emergency situation at (Telephone number) Number # _____________________________ Southern Arizona Orthopedics will use any means that our office deems appropriate to communicate with a patient, or an emergency contact, in an emergency situation even if this requires our office to disregard the restrictions requested on this form. Signature of Patient or Representative: Name of Patient or Representative: Date: ______________________________ ______________________________ ______________________________

Acknowledgement of Use and Disclosure of Protected Health Information for Treatment. Payment , and Healthcare Options Southern Arizona Orthopedics Protected health information is individually identifiable demographic or health information that is maintained or transmitted by Southern Arizona Orthopedics in any form or medium. It is necessary for Southern Arizona Orthopedics to use and disclose your protected health information to provide your healthcare. Southern Arizona Orthopedics Notice of Privacy Practices describes in detail how your protected health information can be used and disclosed. You have the right to review the Notice of Privacy Practice prior to signing this document. You can receive a written copy of the Notice of Privacy Practice at your request. By signing this document, you acknowledge that you have been given the opportunity to review our Notice of Privacy Practice; and you acknowledge that you have been informed that Southern Arizona Orthopedics may use and disclose your protected health information for treatment, payment, and healthcare options. You have the right to request restrictions on the use and disclosure of your protected health information for treatment, payment, and healthcare operations. Southern Arizona Orthopedics is not required to agree to your request. However, if Southern Arizona Orthopedics does agree to your request, then your protected health information will only be used within the specified limits. Southern Arizona Orthopedics is allowed, by law, to use and disclose your protected health information for treatment, payment, and healthcare operations even if you do not complete and sign this acknowledgement form. Southern Arizona Orthopedics may release your protected health information to other agents at your request. You will be required to complete a separate authorization form prior to release of information to other agents. Southern Arizona Orthopedics will disclose your protected health information without your acknowledgement or authorization as required by law. --------------------------------------------------------------------I acknowledge that I have been given the opportunity to review Southern Arizona Orthopedics Notice of Privacy Practice; and I acknowledge that I have been informed that Southern Arizona Orthopedics may use and disclose my protected health information for treatment, payment, and healthcare operations. Signature of Patient or Representative: Name of Patient or Representative: Date: _______________________________________ _______________________________________ _______________________________________

The information on this form may NOT be altered, edited or changed.