Patient Forms

Simplify your journey with South Bend Orthopaedics with access to vital forms all in one place. From new patient forms to physician referral and privacy notice forms, we’ve made it easy for you to find and complete the necessary paperwork.

New Patients

As a new patient to our practice, we appreciate you choosing South Bend Orthopaedics. Fill out these forms ahead of time and save significant time during your appointment.

Authorization For PHI Use and Disclosure Form

The Authorization for PHI Use and Disclosure Form grants us permission for the release and sharing of personal health information as specified by the patient.

Patient Health History Form

The Patient Health History Form provides us with essential medical information about the patient, including past conditions, treatments, medications, and relevant health details.

Acknowledgement Form

The Acknowledgement Form confirms the patient’s receipt and understanding of important information regarding payment, treatment, privacy practices, and responsibilities throughout the treatment process.

Patient Referral Form for Physicians

South Bend Orthopaedics looks forward to collaborating with you to evaluate and treat your patients. Our goal is to enhance your practice by offering swift consultations and effective communication. Feel free to reach out to us, and we’ll make every effort to schedule your patients promptly. We are eager to join forces in providing the best care for your patients.

Please have the following information available when calling to schedule a referral appointment.

  • All patients demographics
  • Name of referring physician
  • SBO physician being requested (if applicable)
  • Part of body
  • Any X-ray, MRI, or diagnostic tests
  • Patient insurance with policy number

SBO wants to ensure that we are meeting the needs of our referring physician’s patients. If you have any questions about our orthopedic services or need to schedule a referral appointment for your patient, please call 574-247-9441 and ask for Physician Referral.

Notice of Privacy Practices

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 take patient rights seriously. If you feel that your privacy rights have been violated by South Bend Orthopaedics you may submit a complaint to our Privacy Officer by sending it to [email protected].