Triumph TRIUMPH Patient Portal Exit
Step 1 of 6 Getting Started
Step 1 of 6

A few quick questions

These answers help us route your paperwork correctly.

Reason for your visit

Is this visit related to an auto accident, on-the-job injury, or something else?

Payment method

How do you plan to pay for your visit?

Good Faith Estimate. Federal law entitles you to a written estimate of expected charges before your visit. We'll include one at the end for your acknowledgment.
We work with your insurance. Triumph accepts most major plans. Where we're not in-network, we work directly with your insurer to help you receive coverage.
Step 2 of 6

About you

Your contact information and a photo ID for verification.

Legal name

Required
Required

Demographics

Required

Contact information

Required
Required
Required
Required
Required
Required

Emergency contact

Photo ID

Driver's license, passport, or state-issued ID. We use this to confirm your identity at check-in.

Step 3 of 6

Insurance & billing

Details about how your visit will be paid.

Primary insurance

Insurance card — front

Insurance card — back

Secondary insurance (optional)

Self-pay acknowledgment

You are paying out-of-pocket
We'll provide a written Good Faith Estimate of expected charges before your visit, in accordance with the No Surprises Act. Payment is due at time of service unless other arrangements have been made.
Step 4 of 6

Medical history

Help us understand your symptoms and background.

What brings you in?

In your own words — what's bothering you most?

Required

Where does it hurt?

Check all areas that apply.

Pain severity right now

0 = no pain, 10 = worst pain imaginable

No painModerateWorst pain

Onset & pattern

Treatments already tried

Current medications

Include dose and frequency if you know it. Write "none" if none.

Allergies

Past medical history

Check any conditions you have or have had.

Past surgeries

Social history

Family medical history

Any of these run in your immediate family?

Step 5 of 6

Consents & signature

Please review each attestation, then sign at the bottom.

Notice of Privacy Practices (HIPAA)
I acknowledge I have received or been offered a copy of Triumph Ortho & Spine's Notice of Privacy Practices, which describes how my protected health information (PHI) may be used and disclosed.
Consent to Treatment
I voluntarily consent to receive medical care, including examination, diagnostic testing, and treatment recommended by Triumph Ortho & Spine and its physicians. I understand no guarantees have been made about the results of my care. I may withdraw consent at any time.
Financial Responsibility
I understand I am financially responsible for all charges for services rendered, regardless of insurance coverage. Any co-pays, deductibles, or non-covered charges are my responsibility. If my insurance denies payment, I agree to pay the balance.
Communications Consent
I authorize Triumph Ortho & Spine to contact me about appointments, care, and billing via phone, text message, and email at the addresses provided.
Good Faith Estimate (No Surprises Act)
As a self-pay patient, I am entitled to a Good Faith Estimate of expected charges from Triumph Ortho & Spine at least 3 business days before scheduled services. I understand:
  • The estimate will reflect the reasonably expected charges for scheduled or requested items and services.
  • If I receive a bill that is $400 or more above the Good Faith Estimate, I may dispute the bill through the federal Patient-Provider Dispute Resolution process.
  • Additional services identified during my visit may not be reflected in the initial estimate.
Third-Party Billing Authorization
Because my visit is related to an auto accident or work-related injury, I authorize Triumph Ortho & Spine to bill and communicate with my auto insurance carrier, PIP carrier, workers' compensation carrier, and/or attorney regarding my care, and to release records as reasonably necessary for that billing.

Signature

Sign inside the box with your finger, stylus, or mouse. Your signature will be embedded in the completed PDF.

Sign here
By signing, I attest the information I have provided is accurate to the best of my knowledge.
Required
Required
Step 6 of 6

Review & send

Confirm everything looks right, then download your completed PDF and email it to us.

Please double-check your information above. Once you download and email your PDF, it goes to info@triumphorthospine.com. Our team will confirm receipt before your visit.

Two steps to finish

  1. 1 Download your PDF — it saves to your device.
  2. 2 Attach the PDF and send it to info@triumphorthospine.com.
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