Notice of Privacy Practices (HIPAA)Financial Policy & Appointment Cancellation
Smoking Cessation & BMI/Healthy Weight Management & Fall History

I acknowledge

  • I have been offered the opportunity to review and receive a copy of the Orthopaedic & Sports Medicine Center’s HIPAA policy and Financial policy
    • The Complete Policies for HIPAA and Financial Responsibility are also available on our website under Resources or at any of the receptionist’s desks.
  •  Orthopaedic & Sports Medicine Center (OSMC) has my permission to provide medical documentation to my insurance company in order to obtain reimbursement.
  • I understand that there may be a $35.00 charge if I do not call and cancel my appointment at least one (1) business day prior to the time scheduled.
  • If I am a smoker, my OSMC physician does recommend that I contact my Primary Care Physician regarding a smoking cessation program.  Smoking is harmful to my health and stopping smoking could improve my overall health status. 
  • BMI is a person’s weight in kilograms divided by their height.  If my BMI is not within normal parameters, my OSMC physician does recommend that I contact and consult with my Primary Care Physician for weight management guidance.
  • Fall History: If I am 65 years old or older and I have had either two (2) falls in the last 12 months or one (1) fall resulting in injury, my OSMC physician does recommend that I contact Physical Therapy for a balance and gait assessment.
Digital Signature
I attest that the above information is correct and to the best of my knowledge. I have read and understand the entire contents of the form and have had the opportunity to ask questions regarding the information of this form.
Patient (or Representative Guardian Parent (Signature)