Forms & Payment

Accepts new patients

Medicare Medicaid Workers' compensation Other
Yes Yes Yes Yes

Medical insurance plans and payment options

Lifewise, Nesika, OHP, OMAP, ODS, PC-65, Choice Care, PacificSource, Providence, Regence Life and Health/Blue Cross, Workers Comp.

Patients with no insurance may be eligible for a monthly payment plan with prior approval.

Office information from Michael Krnacik, M.D., Ph.D.

Appointment Office Policy
Contains complete instructions for new patients before they visit our clinic for the first time. Covers appointment policy, payment policy, and expectations of the patient prior to service.

Authorization to Disclose Medical Records
Please complete and sign so that we may obtain your pertinent records from other physicians for your visit in our clinic.

Notice of Privacy Practices
Review this document first, then sign Acknowledgement and Consent Form. This document describes how the practice uses your personal health information for treatment, payment and operations according to the federal HIPAA law.

Patient Acknowledgement and Consent
Acknowlegement and consent to use personal health information for treatment, payment and operations according to HIPAA guidelines.

Patient Financial Responsiblity Acknowledgement

Patient Health History Form

Patient Information Sheet

Contact Information

Umpqua Orthopedics 277 Medical Loop Roseburg, OR USA 97471-1644 View map Phone 541-677-2131 Fax 541-677-2136

Other staff in my practice

Medical Assistant for Dr. Krnacik:
Kelly

Medical Assistant for Dr. Van Anrooy:
Mellissa Huntley

X-ray Tech:
Beth Drummond

Accounts Receivable:
Laura Giles

Scheduling/Referral Coordinator:
Tseitel Phelps

Receptionist:
Dana Hooper

Office Manager:
Lorrie Sutherland

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