Peak Orthopedics - Admission Requirements

Amission Requirements Navigation

Registration Packet
Insurance
Montana Medicaid Reqirements
BCBS Chips Participant Requirements
Worker's Compensation/Industrial Injury Claims
Auto Accident Requirements
Third Party Liability Requirements

Registration Packet

Patient Registration Outline

In an effort to expedite the registration process, please complete the following registration forms and bring them with you to your appointment. It is also a requirement that you bring your insurance card(s). We will make a photo copy of your insurance card(s) to comply with our insurance billing protocol.

Patient Demographic/Insurance Information
Note: In reference to primary/secondary insurance information: it is mandatory that you provide the subscriber’s name, relation to patient, social security number and date of birth.
Patient Information Form (pdf)
Medical History
Please be as thorough as possible to inform our physician of your past and current medical problems.
Note: Medication names and dosage(s) are very important to assist us in your care.
Patient Medical History Form (pdf)
Acknowledgement of Admission Requirements
Please initial next to each policy and sign/date the bottom of the form.
Acknowledgement of Admission Requirements (pdf)
Acknowledgement - Receipt of Privacy Practices
This document outlines the federally mandated regulations regarding your protected health information.
Privacy Practices (pdf)
Financial Policy
Please read thoroughly and sign/date the bottom of the form.
Financial Policy (pdf)

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Insurance

The following is a list of insurance companies that Peak Orthopaedics, PLLC is contracted with.

It is the patient’s responsibility to verify with their insurance carrier Peak Orthopaedics’ contractual status at the time of service. It is recommended that patient’s call the customer service number listed on their insurance card or log onto the website we have referenced.

INSURANCE CARRIER	WEBSITE
Medicare	www.cms/hhs.gov
Medicaid	www.dphhs.mt.gov
CHN (Community Health Network)	www.chnmt.com
Interwest Health	www.interwesthealth.com
Health Connections	N.A.
Health InfoNet	www.healthinfonetmt.com
First Access	N.A.
PPO USA – GEHA	www.ppousanetwork.com
BCBS Traditional Plan Chips Plan Caring Plan Federal Plan	www.bcbsmt.com
Worker’s Compensation/ Industrial Injury (Require Claim Number and Liability Verification)
U.S. Dept of Labor:	www.dol/gov/esa/owep-org
Montana Health Systems:	www.mhs-inc.net/center.asp
State Fund:	www.montanastatefund.com

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Montana Medicaid Requirements

If you have insurance coverage under Montana Medicaid, you must provide our facility with a copy of your Montana Medicaid insurance card. Our office will inquire with Medicaid to verify your eligibility status.

Montana Medicaid requires that participants pay a $4.00 co-pay at the time of service to be compliant with the terms and conditions of their contractual agreement. The only exceptions to this co-pay are Medicaid recipients that are children under the age of 18 and Medicaid recipients that are pregnant women.

Montana Medicaid recipients will also be required to pay their $4.00 co-pay at the time of service if they receive x-rays, injection administration or casting application in their post-surgical global period.

Montana Medicaid recipients will be required to pay for injection medications, casting supplies and durable medical goods distributed by Peak Orthopaedics, PLLC. The patient will be required to sign an ABN (Advanced Beneficiary Notice) recognizing financial liability for these items.

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BCBS Chips Participant Requirements

BCBS Chips participants are required to pay $3.00 at the time of service to be complaint with the terms and conditions of their contractual agreement.

BCBS Chips recipients will also be required to pay their $3.00 co-pay at the time of service if they receive x-rays, injection administration or casting application in their post-surgical global period.

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