Request an Appointment - Midwest Orthopaedics at Rush

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Thank you for your interest in Midwest Orthopaedics at Rush. We are pleased to offer the following Appointment Request Form. Please note that every effort is made to get back to you within 24 hours of submitting this appointment request. If you are not contacted within 24 hours, or wish to speak to the appointment desk directly, please call 312-243-4244 during normal business hours.

MOR Patient Registration

* Name:
* Address:
* City:
* State:
* Zip:
* Day Phone:
* Contact Method
* E-Mail Address:
Insurance Provider:
Work Related?	Yes No
* Area of Concern:	(example: knee, shoulder, etc.)
* Referral Source:	(example: physician or friend's name)
Physician:
* I have read and agree to the terms and conditions outlined within the Privacy Policy. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We respect patient confidentiality and we are required by the State of Illinois and Federal law to maintain the privacy of your protected health information (PHI). Your health record contains PHI about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. The new notice will be effective for all PHI that we maintain at that time. Should our privacy notice change, we will post any revision on our web site at www.rushortho.com. You may also receive a copy by calling any one of our offices to have your copy mailed to you or you may request one at the time of your next appointment. How We May Use and Disclose Your PHI We use and disclose your PHI for a variety of reasons. We may ask for your consent for the use or disclosure of your PHI for the purpose of treatment, payment or our health care operations. We have a limited right to use and/or disclose your PHI for purposes of treatment, payment or our health care operations. For uses beyond that, we must have your written authorization unless the law permits or requires us to make the use or disclosure without your authorization. If we disclose your PHI to an outside entity in order for that entity to perform a function on our behalf, we must have in place an agreement from the outside entity that it will extend the same degree of privacy protection to your information that we must apply to your PHI. However, the law provides that we are permitted to make some uses/disclosures without your consent or authorization. The following offers some examples of our potential uses/disclosures of your PHI. USES AND DISCLOSURES RELATING TO TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS We may disclose your PHI as follows: For treatment: We may disclose your PHI to physicians, nurses and other health care personnel to provide, coordinate or manage your care, including sharing information with outside entities performing ancillary services relating to your treatment, such as lab work or x-rays, for consultation purposes, or health agencies involved in provision or coordination of your care. To Obtain Payment: We may use or disclose your PHI in order to bill and collect payment for your health care services. For example, we may contact your employer to verify employment status or release portions of your PHI to Medicare/Medicaid or private insurer to get paid for services that we provided to you. For Health Care Operations: We may use or disclose your PHI in the course of operating our practice. For example, we may use or disclose information about you to coordinate our business activities. This may include setting up your appointments, reviewing your care, quality assessment activities, training staff and medical students or conducting or arranging for other business activities. Appointment reminders: Unless you provide us with alternative instructions, we may call, e-mail or send appointment reminders to your home or to provide treatment alternatives or other health related benefits or services that may be of interest to you. USES AND DISCLOSURES REQUIRING AUTHORIZATION: For uses and disclosures beyond treatment, payment and operations purposes we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we have already undertaken an action in reliance upon your authorization. USES AND DISCLOSURES NOT REQUIRING CONSENT OR AUTHORIZATION Disclosure to Those Involved in Individual's Care: The practice discloses protected health information to those involved in a patient's care when the patient approves or, when the patient is not present or not able to approve, when such disclosure is deemed appropriate in the professional judgment of the practice. When the patient is not present, the practice determines whether the disclosure of the patient's protected health information is authorized by law and if so, discloses only the information directly relevant to the person's involvement with the patient's health care. The practice does not disclose protected health information to a suspected abuser, if, in its professional judgment, there is reason to believe that such a disclosure could cause the patient serious harm. Further, the practice uses and discloses information as required by law. Uses and Disclosures Required by Law: As required by law the practice discloses protected health information to public health officials. This includes reporting of communicable diseases and other conditions, sexually transmitted diseases, lead poisoning, Reyes Syndrome, and mandated reports of injury, medical conditions or procedures, or food-borne illness. The practice discloses protected health information regarding victims of abuse, neglect, or domestic violence. The practice discloses information about a minor, disabled adult, nursing home resident, or person over 60 years of age whom the practice reasonably believes to be a victim of abuse or neglect to the appropriate authorities as required by law or, if not required by law, if the individual agrees to the disclosure. This includes child abuse and neglect, elder abuse and exploitation, abused and neglected nursing home residents, or disabled adults abuse. The practice informs the individual of the reporting unless the practice, in the exercise of professional judgment, believes informing the individual would place the individual at risk of serious harm or the practice would be informing a personal representative, and the practice believes the personal representative is responsible for the abuse, neglect, or other injury, and that informing such person would not be in the best interests of the individual as determined by the professional judgment of the practice. Uses and Disclosures for Health Oversight Activities: The practice may disclose PHI as required by law for health oversight activities. The information may be used and released for audits, investigations, licensure issues, and other health oversight activities, including, but limited to managed care peer review, or Medicaid or Medicare peer review. Disclosures for Judicial and Administrative Proceedings: In general, the practice may disclose information for judicial and administrative proceedings in response to an order of a court or an administrative tribunal; or a subpoena, discovery request or other lawful process, not accompanied by a court order or an ordered administrative tribunal. Disclosures for Law Enforcement Purposes: The practice may disclose PHI for law enforcement purposes to law enforcement officials. Uses and Disclosures Related to Decedents: The practice may use or disclose PHI as required to a coroner or medical examiner and funeral directors as required by law. Uses and Disclosures Related to Cadaveric Organ or Tissue Donations: The practice may use or disclose protected health information to facilitate organ or tissue donations. Uses and Disclosures to Avert a Serious Threat to Health or Safety: The practice may use or disclose protected health information to public health and other authorities as required by law to avert a serious threat to health or safety. Uses and Disclosures for Specialized Government Functions: The practice may use or disclose protected health information for military and veterans activities, national security and intelligence activities, and other activities as required by law. Uses and Disclosures in Emergency Situations: The practice may use or disclose protected health information as appropriate to provide treatment in emergency situations. In those instances where the practice has not previously provided its Notice of Privacy Practices to a patient who receives direct treatment in an emergency situation, the practice provides the Notice to the individual as soon as practicable following the provision of the emergency treatment. Marketing Purposes: The practice does not use or disclose any protected health information for marketing purposes. The practice does engage in communications about products and services that encourages recipients of the communication to purchase or use the product or service for treatment, to direct or recommend alternative treatments, therapies, health care providers, or settings of care to the individual. These activities are not considered marketing. Research Purposes: In certain circumstances, under the supervision of a privacy board, we may disclose PHI with research staff and their designees in order to assist medical research. Other Uses and Disclosures: The practice does not use or disclose protected health information to an employer or health plan sponsor, for underwriting and related purposes, or to brokers and agents, or for fundraising. If an individual wants the practice to release his or her protected health information to employers or health plan sponsors, for underwriting and related purposes, or to brokers and agents, then he or she can contact the practice and complete an appropriate written authorization. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION You have the following rights relating to your PHI: To request restrictions on uses/disclosures: You have the right to ask to restrict the use and/or disclosure of your health information for treatment, payment, or health care operations, except for uses or disclosures required by law. You have the right to ask to restrict the use and/or disclosure of health information to family members, close friends or other persons you identify as being involved in your care or payment of your care. The practice is not required to agree to a requested restriction. Although the practice will accept and review all requests for restrictions of disclosures of protected health information, the practice does not agree to any restrictions in the use or disclosure of protected health information All requests for restrictions of disclosures must be submitted in writing. They must be sent to the attention of the practice's privacy officer. The privacy officer notifies the requestor in writing that the practice does not accept restrictions of disclosure. To request confidential communications: The practice accommodates all reasonable requests to keep communications confidential. The practice determines the reasonableness based on the administrative difficulty of complying with the request. A request for confidential communications must be in writing, must specify an alternative address or other method of contact, and must provide information about how payment will be handled. The request must be addressed to the practice's privacy officer. No reason for the request needs to be stated. The practice accommodates all reasonable requests. The reasonableness of a request is determined solely on the basis of the administrative difficulty of complying with the request. The practice will reject a request due to administrative difficulty: if no independently verifiable method of communication such as a mailing address or published telephone number is provided for communications, including billing; or if the requestor has not provided information as to how payment will be handled. The practice will not refuse a request: if the requestor indicates that the communication will cause endangerment; or based on any perception of the merits of the requestor's request. To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your PHI upon your written request. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying. Illinois law prohibits charges that exceed the following: $20 handling fee plus 77 cents each for pages 1 through 25, 51 cents each for pages 26 through 50 and 26 cents each for pages 51 to end; plus $3.50 charge per x-ray. All fees are payable at the time of pick up. The practice limits charges to records to the amounts allowed under Illinois law. To request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request, in writing, that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is: (i) correct and complete; (ii) not created by us and/or not part of our records, or; (iii) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the change in the PHI. To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure for treatment, payment, and operations; to you, your family; or pursuant to your written authorization. The list also will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, or disclosures made before April, 2003. We will respond to your written request for such a list within 60 days of receiving it. There will be no charge for up to one such list each year. There may be a charge for more frequent requests. To receive this notice: You have a right to receive a paper copy of this Notice and/or an electronic copy by email upon request. Individual Rights - Authorizations The practice obtains a written authorization from a patient or the patient's representative for the use or disclosure of protected health information for other than treatment, payment, or health care operations; however, the practice will not get an authorization for the use or disclosure of protected health information specifically allowed under the Privacy Rule in the absence of an authorization. The practice will provide a patient upon request a copy of any authorization initiated by the practice (as opposed to requested by the patient) and signed by the patient. The practice does not condition treatment of a patient on the signing of an authorization, except disclosure necessary to determine payment of a claim (excluding authorization for use or disclosure of psychotherapy notes); or provision of health care solely for the purpose of creating protected health information for disclosure to a third party (e.g., pre-employment or life insurance physicals). The State of Illinois requires a specific written authorization to disclose or release of mental health treatment, alcoholism treatment, drug abuse treatment or HIV/Acquired Immune Deficiency Syndrome (AIDS) information. The practice allows an individual to revoke an authorization at any time. The revocation must be in writing and must be sent to the attention of the practice's privacy officer; however, in any case the practice will be able to use or disclose the protected health information to the extent practice has taken action in reliance on the authorization. Individual Rights - Waiver of Rights The practice never requires an individual to waive any of his or her individual rights as a condition for the provision of treatment, except under very limited circumstances allowed under law How to Complain about our Privacy Practices: If you have questions about this Notice, think we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with our Privacy Officer, at One Westbrook Corporate Center, Tower I, Suite 240, Westchester, Illinois 60154, telephone number (877) 632-6637 (877MD Bones). You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights, 233 North Michigan Avenue, Suite 240, Chicago, Illinois 60601. We will take no retaliatory action against you if you make such complaints. Effective Date: January 1, 2004 * I have read and agree to the terms and conditions outlined within the Financial Policy. Office and Financial Policies We would like to thank you for choosing Midwest Orthopaedics at Rush as your medical provider. As one of our patients we would like to keep you informed of our current office and financial policies. We require that you read and sign this document prior to any treatment. Please keep this document for future reference. Canceled Appointments: If you are unable to keep your scheduled appointment, please call our office within 24 hours to reschedule. This will allows us to provide that time slot to another patient. No Insurance: Payment will be due at the time of service. If you are unable to pay your balance in full, you will need to make prior arrangements with our Customer Service Representative or Financial Coordinator. Insurance: Please bring your insurance card with you at the time of your appointment. With insurance plans where we have agreed to participate in the network as a provider, your carrier requires that all co-pays be paid prior to any services being rendered. The co-pay requirement can not be waived by our practice, as it is a requirement placed on you by your insurance carrier. If you do not have your co-pay at the time of your visit, you must provide us a written waiver from your insurance carrier specifically authorizing Midwest Orthopaedics at Rush to waive this requirement. You are responsible for any co-insurance, deductibles or non-covered services not paid by your insurance within the stateâ€™s required time limitation for paying healthcare claims. You will receive a statement from our office indicating what your insurance has paid. Any balance remaining is due upon receipt. HMO or POS: Regarding insurance plans where we participate as a provider, your insurance carrier requires that you obtain a referral from you Primary Care Physician (PCP) before receiving services from another provider, please bring that referral with you. It is your responsibility to know your insurance requirements. Any services received without a referral or proper authorization will be your responsibility. Auto Accident Injury: If your injury is due to an automobile accident, we request that you provide us with any information that will assist us in getting your medical claims paid. This information may include copy of the police report, copy of your auto insurance, medical insurance, names and information on other parties involved. Any unpaid services provided will be your responsibility. Liability Injury: If your injury is a result from another partyâ€™s negligence, we request that you provide us with any information that will assist us in obtaining reimbursement for the services rendered to you. This information may include a copy of the accident report listing claim number and responsible party, medical coverage and/or attorney information. Any unpaid services provided are your responsibility. Workerâ€™s Compensation: If your injury is due to an accident in your work place, please be sure to contact your employer and inform them of your injury. We will need to receive required information from your employer before we can process any of your medical claims. Please have your employer contact our Customer Service Department. Failure to properly report this injury to your employer may result in your claims being denied. Denied claims may become your financial responsibility. Return Checks: A $30.00 charge will be added to your account for any check returned by your bank for any reason. Disability or Insurance Forms: There will be a charge of $15.00 - $35.00 for the completion of medical forms (charge is based upon number of pages and complexity of information requested). Payment is due at the time that you pick-up the forms. Please allow 7 â€“ 10 days for the completion of these forms. If you would like the forms mailed to you or the insurance, payment will be due prior to mailing. Medical Records: We will provide you a copy of your medical records upon request. You will need to sign a letter of release at the time of pick-up. Please allow 7-10 days for us to copy your records. If you wish for your records to be mailed, there maybe an associated fee to cover the mailing costs. You may be charged for additional copies of your medical record, rates charged within Illinois state statutes. X-Rays: We will provide you with a copy of your x-rays upon request. You will need to sign a letter of release at the time of pick-up. Please allow 48 hours from the time of your request. There is a $3.50 charge per x-ray, that is payable at the time of pick-up. If you have any questions or concerns, please contact our Customer Service Department at 877-632-6637. Thank you for allowing us to service you. Patient Financial Responsibility I acknowledge full financial responsibility for services rendered by Midwest Orthopaedics at Rush. I understand that I am responsible for prompt payment of any portion of the charges not covered by insurance, including deductibles and copays. I understand payment of co-pays is expected at time of service, as well as any prior balance I may owe. I also consent that the payment of authorized Medicare insurance benefits be made on my behalf directly to Midwest Orthopaedics at Rush at Rush at Rush for any medical or surgical services furnished. I agree to all reasonable attorney fees and collection costs in the event of default of payment of my charges. Signed ________________________________________ Date ________________________ Consent for Purposes of Treatment, Payment and Healthcare Operations I hereby give my consent to Midwest Orthopaedics at Rush to use or disclose, for the purpose of carrying out treatment, payment, or healthcare operations, all protected health information contained in the patient record of _______________________________________. For a more detailed description of this consent and other uses and disclosures please review our Notice of Privacy Practices. I understand that Midwest Orthopaedics at Rush reserves the right to change its privacy practices that are described in the Notice. I also understand that any Revised Notice will be posted on Midwest Orthopaedics at Rushâ€™ website, available at each office or I may request a copy be sent to me by mail. I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at any time by giving written notice of my desire to do so. I also understand that I will not be able to revoke this consent in cases where the physician has already relied on it to use or disclose my health information. Written revocation of consent must be sent to the physicianâ€™s office Signed ________________________________________ Date ________________________ Acknowledgment â€“ Notice of Privacy Practices I hereby acknowledge receipt of Midwest Orthopaedics at Rushâ€™ Notice of Privacy Practices. The Notice of Privacy Practices provides detailed information about how the practice may use and disclose my confidential health information. I understand that Midwest Orthopaedics at Rush has reserved the right to change its privacy practices that are described in the Notice. I also understand that a copy of any Revised Notice will be provided or made available to me. Signed ____________________________________ Date _____________ If you are not the patient, please specify your relationship to the patient ________________________ Office and Financial Policies/Revised: 10-03

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