Patient Forms
Dear Patient:
Welcome to Black Hills Orthopedic and Spine Center. We are pleased that you
have chosen us to provide you with services. Our providers offer specialty care to patients in the areas of orthopedics, podiatry, rehabilitation and rheumatology and arthritic conditions.
Black Hills Orthopedic and Spine Center has served the Black Hills community and
surrounding areas for over 25 years.
Please complete all forms from the appropriate Welcome Packet and bring them to your appointment. The forms
must be filled out in blue or black ink. If this is the first time that you are
being seen by our physician or physician assistant for this extremity or condition, they need to see any
x-rays including MRI’s, CT Scans, Bone Scans, or any diagnostic testing performed
within the last year that pertains to what we are seeing you for. If these x-rays
were done at either Rapid City Regional Hospital or Black Hills Imaging and you
did not inform us at the time of making your appointment, please call our office
so that we can request these films. If the x-rays/tests were done at another facility
it is the patient’s responsibility to bring these to the appointment. If our physician
saw you at the ER or as an inpatient at the hospital and you are being seen at the
clinic in follow up, you do not need to bring the films. If you have been evaluated
by any other physician for this matter, you must bring that physician’s notes to
this appointment in order for our doctor to have a complete history.
If you are currently a Medicaid patient on the managed care program, PLEASE BRING
YOUR CURRENT MEDICAID CARD AND THE MANAGED CARE REFERRAL CARD at the time of your
appointment or your appointment will NEED TO BE RESCHEDULED.
If we are seeing you for a worker's compensation related injury, our office must be notified.
We need to secure prior authorization for billing purposes or it could delay your
appointment or cause your account to be set up as a self-pay account.
Our office requests that all services be paid in full at the time of service unless
we are a participating provider with your insurance plan. If you are unsure whether
we participate with your particular insurance, you may either contact us or your
insurance company prior to your appointment. Payment may be in the form of cash,
personal check, Visa, or MasterCard. As a courtesy we will file your insurance.
We ask that you bring all insurance cards with you to the appointment. If your insurance
requires an authorization, please bring that with you at the time of your appointment.
Please be aware that we cannot guarantee any payment from your insurance company
as that contract is between you, your employer, and your insurance carrier. Our
fees are the same regardless of whether or not you have insurance. They are based
on the time, care, skill, and judgment we give to our patients, not what insurance
allows. Under certain circumstances our office may extend payment plan arrangements
to a patient’s account. Payments for medical services will not be deferred while
you are awaiting personal injury settlements. Please note that any minor scheduled
for an appointment must be accompanied by a parent or guardian.
If you are scheduled to see one of our orthopedic surgeons please understand that
this is for your initial office visit to determine if surgery is an option for you.
This appointment is not for a surgical procedure.
The addresses to our various clinic locations are listed here
. Please call our office at (605) 341-1414 or 1-800-446-9556 if you have any questions.
We look forward to seeing you!