Center for Hand Surgery, Inc.
Michelle R. Ritter, MD Orthopaedic Hand Surgery
385 Bert Kouns, Building 500, Shreveport, LA 71106
Ph: 318-686-9986 Fax: 318-686-9505
Toll Free: 866-350 HAND (4263)
Welcome New Patient,
Dr. Michelle Ritter and her staff thank you for choosing the Center for Hand Surgery.
Please complete the enclosed forms and bring with you to your appointment or you can fax them
to us at 318-686-9505.
Please arrive a few minutes early so you can fill out additional medical information on our
electronic kiosk. One of our staff will assist you with the touchscreen if needed. Your information is
kept in strictest confidence and is used to submit your insurance claims and provide your health
care.
In order for Dr. Ritter to thoroughly evaluate your medical issue:
1. Please bring any Surgery notes or Test results pertaining to your appointment . These
include X-rays, MRI films, Nerve studies or Lab reports.
2. Please pick up any x-ray films or cd’s of tests and bring them with you.
(Dr. Ritter likes to review all x-ray films and CD’s personally to determine the best
course of action for you. Your referring doctor will not necessarily send these to us and
your insurance may not pay for a repeat test.)
3. Please remember to bring your current insurance card(s), a picture ID, and any co-pay to
your appointment.
4. Please bring your prescription medications and any over-the-counter vitamins, herbs or
medications you are taking.
5. NO FRAGRANCES OR COLOGNES AS SOME STAFF ARE ALLERGIC AND YOU MAY
HAVE TO BE RESCHEDULED.
If you have any questions about getting your medical information from another doctor, please call
our helpful staff for assistance.
We look forward to meeting you.
© Center for Hand Surgery, Inc.
Center for Hand Surgery
Michelle R Ritter, MD Orthopaedic Hand Surgery
385 Bert Kouns, Bldg 500, Shreveport, LA 71106
Toll Free:866-350-HAND or 318-686-9986 Fax: 318-686-9505
Patient Name__________________________________________________________________________________
Last
First
Middle
Maiden
Address_______________________________________________________________________________________
Street
City
State
Zip
* E-mail address ________________________________________________________________________
Email Required to access the Patient Portal
Home telephone (____)_________________Work (____)___________________Cell (____)___________________
Please circle preferred phone for reminder call:
HOME
WORK
CELL
Date of Birth____________________SSN_________-_______-__________Occupation______________________
Employer’s name and address:_____________________________________________________________________
*Primary Insurance:_____________________*Policy number________________________________________
Subscriber if different from name on card__________________________________________________________
Subscriber DOB_______________SSN______-______-______ Relationship to Patient____________________
Secondary Insurance___________________Policy Number___________________________________________
Who is Responsible for Payment? Same as Above_____
If Different from Patient fill in below:
Name__________________________________________ Relationship to patient__________________________
*Date of Birth__________________________ SSN____________-________-_____________
Required
*Mailing address: _____________________________________________________________________________
Street or PO Box
___________________________________________________________________________________________
City
State
Zip
Daytime phone number of person responsible for payment: (__________)____________________________
© Center for Hand Surgery, Inc.
Center for Hand Surgery
Michelle R Ritter, MD Orthopaedic Hand Surgery
385 Bert Kouns, Bldg 500, Shreveport, LA 71106
Toll Free:866-350-HAND or 318-686-9986 Fax: 318-686-9505
Patient
Name______________________________________________DOB___________/_________/______________
*PHARMACY Preference_____________________Phone/Location______________________________
Required
IT IS PREFERABLE THAT YOU BRING YOUR MEDICATION BOTTLES AND ANY VITAMINS
AND HERBALS TO YOUR APPOINTMENT AND THEN YOU CAN SKIP THIS FORM.
Do you take any prescription or non-prescription medications, vitamins or herbals?
Please list the name, strength and dosage:
Yes______ No_______
EXAMPLE: Atenolol 25 mg 1/day
1.__________________________________________
2.___________________________________________
3.__________________________________________
4.___________________________________________
5.__________________________________________
6.___________________________________________
7.__________________________________________
8.___________________________________________
9.__________________________________________
10.___________________________________________
If female, are you currently pregnant? Yes____No____
How many weeks?_________________________
Primary Care Doctor: Name___________________________________Phone_____________________________
**Referring doctor: Name________________________________ Phone__________________ None_________
**Please know that we are required to send a copy of your treatment plan to the
doctor who referred you to our office for treatment. If the referring doctor is not your
physician (e.g. a family friend or employer) please tell the nurse.
.
© Center for Hand Surgery, Inc.
INJURY DETAILS
NAME____________________________________________DOB_____/_____/________
Last (required)
First (required)
mm/dd/yyyy (required)
1. What was the date and time of the injury or when did the problem first occur?
Date_____________ Time____________ Approx Date if unsure _____________________
2. What is the name of the place_______________________________________and address
_____________________________________________________________where it occurred?
3. How did it happen? Be specific. _________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Hand___________ Wrist__________ Finger(s)________________ Arm_________ Elbow_________
Right or Left
Right or Left
Which One?
Right or Left
Right or Left
4. Is this work related? Yes___ No____ Have you reported it to your employer? Yes___ No____
If reported, Name and phone number of Employer or Adjuster Responsible for payment.
Please understand that your health insurance will not cover a work related
problem.
5. Is this the result of an Auto Accident?
Yes____ No____
We do not bill third party insurers or health insurance for auto accidents.
6. Do you have a lawyer regarding this problem? If yes, give name and phone number.
Name:_____________________________________________Phone:______________________________
_____________________________________________________________________________
_
Signature of Patient/Parent if Minor
Date
_________________________________________________________
Office Staff Signature
© Center for Hand Surgery, Inc.
Date
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Current privacy regulations preclude us relaying information to anyone other than our patients, including
spouse and children. This means that if we need to confirm an appointment time for the office or surgery
time, we may not leave a message with someone at your home or on your answering machine,
unless you give permission. Additionally, we may not even leave a message to return the call to our
office, since that would disclose that you are being treated here. We cannot discuss test results or
prescriptions with family members who call on you behalf, unless you designate them below.
In addition to information which we must release to your insurance company, referring or consulting
physicians, employers, and Worker’s Compensation case managers or adjustors, please list below any
other individuals who may receive information, either in writing or verbally. This authorization is valid until
revoked in writing below.
Name/Relationship
Phone
appts
surgery
billing
Info
medical
info 
1.
2.
3.
4.
What may be left on answering
machine or cell phone?
IF YOU DO NOT WISH ANYONE TO HAVE ANY INFORMATION, PLEASE CHECK THE BOX BELOW.

I do not authorize the release of information to anyone.
(please check)

I have received a copy of the Notice of Privacy Practices
_______________________________
Print Patient Name
_________________________________
Patient Signature
_______________________________________
Date
_______________________________________
Office Staff Signature
REVOCATION (to be used only to revoke authorization above)
 I hereby revoke the above authorization to release information.
Patient Signature________________________________________Date________________________
Office Staff_____________________________________________Date_______________________
© Center for Hand Surgery, Inc.
CONSENT TO TREATMENT
I/we consent to treatment, diagnostic procedures or other services
deemed necessary by my physician and/or any consultants she chooses.
Said treatment may include examination, x-ray, injections, cast placement
or removal, as well as minor surgical procedures (e.g. pin removal, foreign
body removal, and wound closure).
I/we agree to assign to the Center for Hand Surgery, Inc. any benefits
due me by the insurance carriers for services rendered by the physician or
facility. Should benefits be insufficient, I/we also authorize the release of
any information required to facilitate payment. I/we also authorize the
release of any information necessary to complete work restriction or
disability forms pertinent to my treatment.
My signature indicates that I fully understand and agree to the above.
Patient or Guardian Signature_____________________________________
Please Print Name _____________________________________________
Patient unable to sign because____________________________________
Office Staff Signature___________________________Chart #__________
Date_________________________
© Center for Hand Surgery, Inc.
Center for Hand Surgery
Michelle R. Ritter, MD, FAAOS
385 Bert Kouns, Bldg 500, Shreveport, LA 71106
318-686-9986 Toll-free 866-350-HAND (4263) Fax: 318-686-9505
DATE__________________________
PATIENT
NAME___________________________________________DOB______/______/______
NON-MEDICAID PARTICIPANTS:
I understand that I am responsible for payment to the Center for Hand Surgery, Inc. for coinsurance, deductibles, or for any other charges deemed my responsibility by my insurance
carrier. If I have no insurance, I agree to pay in full, any services rendered to me or to
whom I am responsible for payment.
MEDICAID PARTICIPANTS:
The Center for Hand Surgery and Dr. Michelle R. Ritter are not in the MEDICAID network and
are unable to bill MEDICAID for services rendered to you. If MEDICAID is your primary
insurance, you will be responsible for the entire cost of any office visits, surgeries, or other
services provided for you.
If MEDICAID is your secondary insurance, you will be responsible for any unpaid balance
which your primary insurance requires you to pay. We will not bill MEDICAID for any
balance you might owe.
By signing this form, you agree to be responsible for any unpaid balance remaining after
any other insurance has paid or if there is no other insurance, you agree to pay
in full, for any services rendered to you or any person for whom you are legally responsible.
____________________________________________ _________________________________________
Responsible Party Signature
Please Print Full Name
_____________________________________
___________________
Medical Office Staff Signature
Date
© Center for Hand Surgery, Inc.