Patient Forms

To Our Patients

Welcome to Longview Orthopedic Associates. We are pleased that you have selected us as your health care provider.

There are three separate forms we need you to print, fill out completely, and bring to your appointment at our office. The Patient Information Sheet contains the information we will be entering into our computer system. We will submit your insurance claim for you if we have the correct billing information at the time of your appointment. Co-payment amounts are due at the time of your visit. If you are not covered by insurance, please bring $75.00 to your initial visit. Payment arrangements will be made on any balance at the time of your first appointment.

The Medical History Questionnaire is necessary for your medical provider to have this information in order to effectively and safely treat you. We would also appreciate your bringing a list of your current medications.

As you may or may not be aware, a federal law was enacted to protect your privacy within medical offices. By law, we must provide you with a Notice of our Privacy Practices. This notice is included on our website. Your signature acknowledging receipt of this notice is required by the Privacy Act. Please sign the page with the acknowledgment of Receipt of Privacy Notice and the Insurance Authorization and Assignment, and, if appropriate, the Medicare Authorization of Assignment. In addition, we ask that you please complete and sign the Records Release Authorization.

If you have had x-rays taken at Kaiser, Longview Radiology or Open Advanced MRI, please call the facility and confirm that they will deliver them to our office for your appointment. If you have had x-rays taken at any other facility besides St. John or the previously mentioned facilities, you will need to bring them to your appointment.

If you have questions, please contact our office at (360) 501-3400. We look forward to seeing you.

Doctors and Staff
Longview Orthopedic Associates

Patient Forms

Medical History Questionnaire

Patient Information Sheet

Insurance Authorization & Assignment

Records Release

 

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