Our orthopaedic surgeons use special orthopaedic history forms to assist them in the evaluation, diagnosis and management of your orthopaedic problem. Many patients appreciate having the time prior to their appointment to completely document their symptoms. We have special forms that are unique to your physician’s subspecialty.
We look forward to the opportunity of managing your orthopaedic problem. Please remember to bring the completed forms with you to your appointment. If you have any questions please do not hesitate to call our office.
Please click on a physician tab to download their specific forms
- Dr. Noyes
- Dr. Siegel
- Dr. Lindenfeld
- Dr. Andrews
- Dr. Galloway
- Dr. Hasan
- Dr. GJ Sammarco
- Dr. VJ Sammarco
- Dr. Busam
MEDICAL RECORDS RELEASE – If you need us to release a copy of your medical record we will need a written authorization. You may use this form or provide a letter or other written notice giving us your authorization.
ADVANCE BENEFICIARY NOTICE (ABN) – An ABN is a written notice from Medicare (standard government form CMS-R-131), given to you before receiving certain items or services, notifying you: Medicare may deny payment for that specific procedure or treatment. You will be personally responsible for full payment if Medicare denies payment. An ABN gives you the opportunity to accept or refuse the items or services and protects you from unexpected financial liability in cases where Medicare denies payment. It also offers you the right to appeal Medicare’s decision.
Our physicians and physical therapists participate in most insurance plans. Our staff handle inquiries by their area of expertise and our contact information is shown below along with a current list of major insurance plans that we accept. Not all insurance plans are listed. Insurance directories or information that you receive from your employer may not always be current whether it is online or in printed form. If you don’t see your plan listed or have questions as to our participation please call us! Prior to your appointment our staff can answer general questions about payers but will not be able to answer detailed questions about your specific plan or your specific benefits. It is always the patient responsibility to understand their plan benefits including deductibles, co-pays including in or out-of network benefits if applicable. Many patients do not always understand insurance terms but are hesitant to ask what they mean. If you aren’t sure about your benefits and what services may or may not be covered please check with your insurance carrier or your employee benefits department. We are always happy to talk to you and will help in any way we can.
Calls are handled according to your insurance type. Please choose from the following 5 digit extensions, dialed after the general number
•Phone 513.347-9999
•Fax 513.346.7297
•Business Office Manager:
92105
•Anthem, Humana & Motor Vehicle:
92109
•Aetna, Cigna, Healthspan, Medical Mutual:
92115
•Workers’ Compensation
92104
•Medicare, Medicaid, Healthnet Federal:
92107
•Other insurance plans not listed:
92115
•Payment questions:
92101
•To update patient information and all other questions:
92112
CSMOC INSURANCE PLAN AND MCO PARTICIPATION
Click Here for Complete Printer Friendly List
We participate in most major insurance plans. Please see Billing Insurance Tab for a complete list. If you have questions as to our physician or physical therapy participation in your plan please contact us.
Cincinnati SportsMedicine participates in a variety of insurance plans and will be happy to bill your insurance carrier for your services. Managed care co-payments must be paid before seeing your physician and physical therapist. We accept cash, personal checks, Visa, MasterCard, American Express and Discover. We do understand that insurance payments are sometimes delayed. However, even when an insurance claim is filed, you will receive a statement each month if your account has a balance due. Our financial policy is shown below. We welcome calls or inquiries from our patients, their representatives or payers at any time. We are here to help you and assist you!
We try our best to handle your requests for prescription refills quickly. Call your physician’s medical secretary during normal business hours. Please have the prescription and your pharmacy name and phone number available. Please call 513-347-9999 and press the prompt for your physicians medical secretary.
Dr. Frank R. Noyes – Donna McCloy 513-794-8471 or dmccloy@csmoc.com
Dr. Mark G. Siegel – Kristi Rogers 513-794-8470 or krogers@csmoc.com
Dr. Thomas N. Lindenfeld – Judy Toerner 513-346-7289 or Jtoerner@csmoc.com
Dr. Michelle Andrews- Zoe Ann Binne 513-346-7294 or zabinne@csmoc.com
Dr. Marc T. Galloway – Lonnya Hornsby 513-346-4518 or lhornsby@csmoc.com
Dr. Samer S. Hasan – Deanna Piercefield 513-346-4520 or dpiercefield@csmoc.com
Dr. G. James Sammarco – Michelle Jensen 513-346-413 or mjensen@csmoc.com
Dr. G. James Sammarco – Michelle Jensen 513-346-413 or mjensen@csmoc.com
Dr. Matthew L. Busam – Toni Harms, RN 513-346-4519 or tharms@csmoc.com
Our physicians have privileges at all of the major hospitals within the Greater Cincinnati area. Please see the links below for information on a specific facility.
Before your surgery can be scheduled, our benefits verification coordinator will contact your insurance company to verify your coverage. This verification is for our business purposes only and does not relieve you of the responsibility of any deductibles, co-payments or other specific provisions of your particular policy. All patients being admitted to the hospital for surgery or other treatment are strongly encouraged to speak to their insurance company as soon as possible to determine their benefits for all services provided including physician services, anesthesia, hospitalization (whether in or out patient services are provided) and radiology services that may be needed during hospitalization or consultation.
Many insurance companies have mandatory second opinion programs for certain procedures. You must check with your insurance carrier to see if a second opinion is required
We are affiliated with the following hospitals and surgical centers:
| Bethesda North Hospital | Bethesda North Hospital Ambulatory Center | Good Samaritan Hospital |
| Greater Cincinnati Surgery Center | Jewish Hospital | Kenwood Surgical Center |
| St. Elizabeth Medical Center | ||
