Shasta Orthopaedics Registration Forms
For your convenience, you can download the following forms. Prior to your appointment the Patient Registration and Patient History forms must be completed and signed and the Notice of Privacy Practices must be read and signed.
Forms
- Online Patient Registration Form (Form includes Common Interest Disclosure and Financial Policies information.) »
- Patient Registration Form (Form includes Common Interest Disclosure and Financial Policies information.) – PDF file [122K] »
- Patient History Form – PDF file [213K] »
- Notice of Privacy Practices – PDF file [80K] »
- Open Payment Database Acknowledgement Form – PDF file [124K] »
Once you have completed the forms:
Fax:
530-242-9460
Mail:
Shasta Orthopaedics
1255 Liberty Street
Redding, CA 96001
You should receive a call within 1 business day of receipt confirming we have received your form. If you have any questions, please call 530-246-2467
Notice To Patients
BEGINNING JANUARY 1, 2023 all physicians must provide written notice to patients (including those patients of Shasta Orthopedics & Sports Medicine and Liberty Physical Therapy) on the initial visit about the Open Payments database and retain a copy of this notice in the medical record (which may be stored electronically)
“The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.”
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided above. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices and biologics to physicians and teaching hospitals be made available to the public.”
See link above to complete the Open Payment Database Acknowledgement Form.