PATIENT FORMS AND OFFICE FORMS
Preparing for your visit:
If you are a new patient to our facility, please be prepared to provide the following information:
- Name
- Address & Phone Number
- Date of Birth
- Social Security Number
- Insurance Card
Capstone Orthopedics & Sports Medicine:
New Patient Form
Record Release to Capstone
Record Release from Capstone
Financial Policy
HIPAA Notice
Patient Authorization Form
Patient Consent
Alliance Orthopedics & Sports Medicine:
The Woman’s Place:
Laser Hair Removal Consent and Information
Notice of Privacy Practice
Sonogram Instruction Sheet
Gynecology Exam Consent Form for Minors
Summit Surgical:
New Surgical Patient
Notice of Privacy Practice
Release of Information
Anesthesia Evaluation Sheet
Colonoscopy Patient History
Surgery Instruction Sheet
Hibiclens Preparation
Colonoscopy Preparation Instructions
Pinnacle Rehabilitation & Sport Performance:
New Rehabilitation Patient
Notice of Privacy Practice
Release of Information
KSHSAA Sports Physical Form
Mirage Imaging:
Notice of Privacy Practice
MRI Screening Form
Notice of Ownership
Release of Information
Financials:
The Summit contracts with many insurance companies. We are required to collect your designated co-pay at the time of service. Please be prepared to pay your co-pay at each visit. Without it, you may be required to reschedule. If you have questions about your coverage, please contact our office prior to your appointment.
Self-pay patients and patients without proof of insurance are required to pay $200.00 in cash, check, or credit card at the time of service. In instances where the visit charge is higher, you will be billed for the difference. Failure to bring your expected payment may result in the rescheduling of your appointment.
Contact Customer Service — customerservice@summitks.com
Notice of Nondiscrimination
The notices below describe your right to receive health care services regardless of race, color, national origin, age, disability or sex. You also have the right to receive free language assistance services. Please read the notice carefully.
Arabic – Notice of Nondiscrimination
Burmese – Notice of Nondiscrimination
Chinese – Notice of Nondiscrimination
Dutch – Notice of Nondiscrimination
French – Notice of Nondiscrimination
German – Notice of Nondiscrimination
Hmong – Notice of Nondiscrimination
Japanese – Notice of Nondiscrimination
Korean – Notice of Nondiscrimination
Lao – Notice of Nondiscrimination
Russian – Notice of Nondiscrimination
Spanish – Notice of Nondiscrimination
Swahili- Notice of Nondiscrimination
Tagalog – Notice of Nondiscrimination
Vietnamese – Notice of Nondiscrimination
Statement of Nondiscrimination
Arabic – Statement of Nondiscrimination
Burmese – Statement of Nondiscrimination
Chinese – Statement of Nondiscrimination
Dutch – Statement of Nondiscrimination
French – Statement of Nondiscrimination
German – Statement of Nondiscrimination
Hmong – Statement of Nondiscrimination
Japanese – Statement of Nondiscrimination
Korean – Statement of Nondiscrimination
Lao – Statement of Nondiscrimination
Russian – Statement of Nondiscrimination
Spanish -Statement of Nondiscrimination
Swahili- Statement of Nondiscrimination
Tagalog – Statement of Nondiscrimination
Vietnamese – Statement of Nondiscrimination
Are you having trouble reaching us?
After extensive troubleshooting on our phone system, it appears that patients calling into our phone
system using iPhone 6 and above are experiencing connection problems.
Due to a known issue with iPhone 6/6S and beyond, patients may have issues accessing our phone
system. When our phone system answers, callers are unable to enter the correct extension and/or
option. This problem has to do with the way the iPhone sends its tones.
In order to resolve this problem, users may change their phone settings.
1. On your iPhone, go to Settings
2. Tap on “Cellular”
3. Tap on “Cellular Data Options”
4. Tap on Enable LTE
5. Tap on “Data Only”
6. Restart your phone
Once your phone has restarted, it will send the correct tones that will allow you to reach our staff. For
more information, visit Apple’s support website.
