Billing & Insurance

Insurance Carriers | Insurance Forms

If you are a new patient or have not been here for a while, we ask that you provide us with some information. This information will allow us to contact you if necessary and to assist us in filing insurance claims.

We also ask that you bring along your insurance card when you come for your appointment.

Insurance Carriers

We are happy to assist you in filing your insurance claims. We are currently a provider for the following insurance carriers:

• Accountable Health Plan

• Araz (America's PPO)

• Avera Basic Choice Health Plans

• Blue Cross Blue Shield of Iowa (Alliance Select)

• Blue Cross Blue Shield of Minnesota (Blue Plus/Blue Choice)

• Blue Select/Blue Cross Blue Shield Federal

• Champus Tricare Standard & Prime Remote

• Choice Plus (Bayer Health Coalition)

• Cigna

• Coventry Health Care

• DakotaCare

• Dakota Care Design

• Dakota Care State Employees

• First Choice

• Hagen Benefits

• Health EZ

• Health Partners

• LaborCare - United Healthcare

• Medica Choice Select & Medica Passport

• Medicaid Programs for IA, MN, NE, SD

• Midlands Choice

• Midwest Select

• Mutual of Omaha

• Patient's Choice

• Preferred One

• PrimeWest

• ProNet

• Select First

• Sanford Health Care System

• TLC

• Ucare

• Wassau/Patient's Choice Avera Tri-state Network

• Wellmark BCBS of SD

If you do not see your plan listed above, please call our office to find out if Orthopedic Institute accepts your insurance. Insurance co-pays are due upon your visit.
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Insurance Forms

NO PHYSICIAN REFERRAL IS NEEDED UNLESS REQUIRED BY YOUR INSURANCE

If you are a new patient to Orthopedic Institute, please download, print and complete the following form and bring with you to your appointment.

If you are a returning patient and you have new insurance information or this is a new injury that can be submitted from another insurance source (example: car accident or workers compensation), please download, print and complete the Patient Information Form attached below and bring with you to your next appointment.

Patient Information Form:
Download (PDF, 144.60 kB)

Release of Records
Orthopedic Institute releases copies of patient records upon request provided we receive a valid authorization signed by the patient or legal representative. Download...

Release of Verbal Information
Before we can speak to anyone requesting information on a specific patient, we need the patient’s permission to speak to someone on his/her behalf. Download...

Consent for Treatment of a Minor
College students, athletes and other minors who come in for treatment without their parent/legal guardian need to have a permission form signed by their parent/legal guardian in order for us to provide treatment. Download...

Medicare Benificiary Authorization Claim Form
If you are a Medicare patient, it is critical for you to download and sign this Medicare signature form to allow us to bill Medicare. Download...

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 AND RETAIN A COPY FOR YOUR RECORDS. Download...

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NO PHYSICIAN REFERRAL IS NEEDED UNLESS REQUIRED BY YOUR INSURANCE

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