Patient Resources and Forms

Thank you for selecting Missoula Bone & Joint in Missoula, Montana for your orthopedic and sports medicine care. To schedule an appointment, please call us at (406) 721-4436 or use our online appointment request form. If you have a question about obtaining your medical records, CALL our medical records department directly at (406)721-4436 ext.5937

Below you will find a wealth of helpful resources regarding our practice, including patient forms for an orthopedic visit, physical therapy, surgery, and MRI. If you have a question, give us a call and one our friendly representatives will be happy to help.

Information for New Patients

  • To ensure we have your accurate medical history available at your initial orthopedic appointment you can either:
    1. Print and complete our required New Patient Forms and bring with you to your appointment, OR
    2. Please bring all necessary information with you to accurately complete all your medical and surgical history, and an updated list of all your medications.
  • Please check in 15 minutes prior to your scheduled appointment to complete paperwork unless you have done so ahead of time. Remember to bring all forms to your appointment.
  • Bring your insurance card to every appointment. You will be asked to pay your insurance co-pay and/or a portion of your bill at each visit.
  • Contact your insurance carrier prior to your appointment as some plans require prior approval for services. Patient benefits and eligibility can be confirmed through your insurance plan.
  • You may be asked to send all pertinent medical records, X-rays, and/or scans prior to your appointment.

Red Flag Rules: In an effort to comply with federal Identity Theft Laws, Missoula Bone & Joint now requires that patients present photo identification for treatment. Please contact our office with questions regarding this policy. Thank you for helping us to protect you.

Our goal is to minimize your wait time prior to your scheduled appointment. Please understand that emergencies and delays occasionally occur. Patience in these situations is greatly appreciated and we will do our best to keep you informed if such delays do occur.

Patient Forms

Once you have made your initial orthopedic appointment it is time to provide us with an accurate medical history.

To ensure we have your accurate medical history available at your initial orthopedic appointment you can either:

  1. Print and Complete Clinic Forms 1-5 below prior to your visit, OR
  2. Please bring all necessary information with you to accurately complete all your medical and surgical history, and an updated list of all your medications, OR use your online patient portal to update medications prior to your appointment.

Established patients can update forms online through our patient portal or print and complete Form # 2 below. If you need help setting up or accessing the patient portal, please call our office at (406)721-4436 ext. 5937 and we’ll be happy to help.

If you are scheduled for physical therapy, surgery, or an MRI, please complete the appropriate forms below and bring them with you to your appointment.

Orthopedic Clinic Forms

  1. Patient Registration Form
  2. New Patient Health History Intake Form  OR Established Patient Intake Form
  3. Patient Financial Policy
  4. Notice of Privacy Practices
  5. Notice of Privacy Practices Acknowledgement Form
  6. MBJ Release of Information
  7. Consent to Treat Minors Form
  8. Surrounding Area MRI and X-ray Facilities

For New patients scheduled with Dr. Mark Channer and Alex Ramsey, PA-C: Please complete the Dr. Channer New Patient Intake Form

For New patients scheduled for a neck or back evaluation with Dr. Zackery Witte, Dr. Lindsey Beck, Joan, or Amie: Please complete the New Patient Neck and Back Form

Physical Therapy Forms

Surgery Center Forms

Patient Financial Policy for Ambulatory Surgery Center

Patient Instruction Sheet - before surgery, day of surgery, after surgery and at home.

Before Surgery: You will be asked to fill out Pre-Surgery forms with the Orthopedic Assistant for your Provider at your clinic visit prior to your surgery.

MRI Forms

Your answers to the questions on the MRI Metal Screening (page 2) will help us determine whether an MRI examination is safe for you based on your history. In addition, we need to determine whether there are any factors that may interfere with your study or may cause difficulty with the scan results.

The Federal Government (Patient Protection and Affordable Healthcare Act, Sections 6409 and 6003 dated March 23, 2010) mandates we provide information on facilities other than those owned by our physicians. You have the right to choose your facility. If you would like to receive services at another facility we will be happy to provide you with a referral. Here is a list of facilities: Surrounding Area MRI and X-ray Facilities

Before Your MRI Appointment

To save time at your MRI appointment, please fill out this MRI Patient History Form, Print Out and Bring With You to your MRI appointment.

If your procedure involves the use of contrast dye, you will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear.
Contrast Information

Nutrition Information

Nutrition is Vital

Nutrition is vital to overall health and wellness - the one true medicine that fuels your body and helps it heal. For this reason, following a balanced diet before, during, and after major surgeries is important to your recovery.

Pre- and Post- Surgery Nutrition Tips Handout

Calcium Content of Foods Handout

High Calcium Foods Handout

Healthy eating and regular physical activity are crucial to adding years to your life and reducing your risk for chronic disease. Nutrient needs change with age and several key foods are important for strong bones and joints, improving memory, and maintaining a healthy body weight. Live your most vibrant years!

Healthy Eating Tips for Healthy Bones Handout

Osteoporosis Nutrition Therapy Handout

Insurance / Payment / Billing

Paying Your Bill Online: when paying your bill online, please make sure that you are going directly to the Missoula Bone & Joint Online Bill Pay Option. If you pay via a different link, for example doxo.com you will be charged a service fee (they are a third party company with no affiliation to us). Missoula Bone & Joint does not charge a service fee to process online payments. If you have questions about paying your bill, please call our billing department directly at (406) 532-8065

Insurance: At Missoula Bone & Joint, we are preferred providers with many insurance companies, including workers’ compensation and Medicare. Please contact your insurance company to verify eligibility and coverage. The following is a list of insurances that we are contracted with as well as preferred provider organizations (PPOs):

 This list changes from time to time so please call your insurance company before your visit or give us a call (406) 532-8779.

  • Allegiance & Cigna Allegiance
  • Blue Cross (Traditional, FEP, HMK, Medicare Advantage PPO and HMO, HELP, Blue Focus, Blue Options)
  • Medicare **
  • Missoula County Benefits
  • Montana Health Co-op
  • Pacific Source
  • Pacific Steel
  • Railroad Medicare
  • Tribal Health
  • Tricare West Region
  • VA Triwest
  • Allegience PPO
  • First Choice PPO
  • Health InfoNet PPO
  • Interwest PPO
  • Multiplan PPO
  • Western Integrated Care

* We are NOT contracted with Humana Gold, a Medicare HMO, because of the pre-authorization requirement by your primary care physician for every service item which causes treatment delays as well as non-payment of services. We are sorry for any inconvenience this causes you. We are contracted with BCBS Medicare Advantage and regular Medicare.

**We are NOT contracted with AETNA, Cigna, Corvel/Corecare, First Health/Coventry, HEHA, Integrated Health, Medicaid of Idaho, New West Medicare, OWCP, PPO USA, Preferred Medical Claim Solutions, Rockport, Three Rivers Pro. Net, Sterling Medicare Select, Tricare (West Region), United Healthcare, Champ VA.

Insurance Information for Veterans:

We do accept and bill to VA Triwest, Tricare, and Tricare for Life. We can help you navigate the system to get you the care you need. If you have questions please call our billing department at (406) 532-8779We are not contracted with Champ VA.

Insurance Information for Urgent Care Patients:

Missoula Bone & Joint is not a free-standing Urgent Care facility. We are required to bill your urgent care visit to your insurance company as an "Office" visit instead of an "Urgent Care" visit. What this means is that your insurance company may pay the benefits differently if billed under "Office" versus "Urgent Care" and your out-of-pocket expense may differ.

Attention Patients with Missoula County Benefits:

If you have a NEW injury and are being treated through Urgent Care, you are responsible for a $15 co-pay at your initial visit. The first set of x-rays are covered at 100% but you will be responsible for any deductible or co-insurance amounts for additional services provided (i.e. DME, casting, injections). In addition, you will be responsible for any deductible or co-insurance amounts for any subsequent visits.

Payment: If your insurance plan requires you to pay a co-payment, co-insurance, and/or a deductible, you will need to pay at the time of your visit. For your convenience we accept cash, checks, Visa, MasterCard, Discover, and American Express. If you need to speak to us with regards to payment please call our Billing department: for a question related to your bill or insurance, please call our billing specialists at (406) 532-8779. To pay a bill call (406) 532-8065.

Another Payment Option:

Missoula Bone & Joint offers an easy, flexible financing option to help you pay for your healthcare costs. BHG Lending can offer low monthly payments that fit your budget, and pay your medical bill over time. Visit bhgpatientlending.com/patients for more information.

Surgery: If surgery is required, separate statements will be sent to you for each provider of services. You may receive billing from each of the following:

  • Physician
  • Surgery Center or Hospital
  • Surgical Assistant
  • Anesthesiologist
  • Pathology/Lab
  • Durable Medical Equipment (DME) Providers

Workers’ Comp: You are required to provide the following information upon scheduling your appointment:

  • Work comp carrier and address
  • Date of injury
  • Claim number
  • Employer at time of accident
  • Adjustor and contact number

This information will ensure accurate and timely filing of your claims. Without this information we will be unable to submit your claim to your work comp carrier and, therefore, will ask for payment at time of service.

If your claim is denied or not paid within a timely manner, we request that you file a personal claim with your health insurance and pay the charges in full. We recommend you notify your employer should there be any delays in settling your workers’ compensation claim.

Billing: If you have a question related to your bill or insurance, please contact our billing specialists at (406) 532-8779. To pay a bill, call (406) 532-8065 or you may pay your bill online.

No Surprises Act

No Surprises: Understand your rights against surprise medical bills

The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. It also establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.

Starting in 2022, there are new protections that prevent surprise medical bills. If you have private health insurance, these new protections ban the most common types of surprise bills. If you’re uninsured or you decide not to use your health insurance for a service, under these protections, you can often get a good faith estimate of the cost of your care up front, before your visit. If you disagree with your bill, you may be able to dispute the charges. Here’s what you need to know about your new rights.

What are surprise medical bills?

Before the No Surprises Act, if you had health insurance and received care from an out-of-network provider or an out-of-network facility, even unknowingly, your health plan may not have covered the entire out of-network cost. This could have left you with higher costs than if you got care from an in-network provider or facility. In addition to any out-of-network cost sharing you might have owed, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called “balance billing.” An unexpected balance bill from an out-of-network provider is also called a surprise medical bill. People with Medicare and Medicaid already enjoy these protections and are not at risk for surprise billing.

What are the new protections if I have health insurance?

If you get health coverage through your employer, a Health Insurance Marketplace®,1 or an individual health insurance plan you purchase directly from an insurance company, these new rules will:

• Ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
• Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.
• Ban out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.
• Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).

What if I don’t have health insurance or choose to pay for care on my own without using my health insurance (also known as “self-paying”)?

If you don’t have insurance or you self-pay for care, in most cases, these new rules make sure you can get a good faith estimate of how much your care will cost before your receive it.

What if I’m charged more than my good faith estimate?

For services provided in 2022, you can dispute a medical bill if your final charges are at least $400 higher than your good faith estimate and you file a dispute claim within 120 days of the date on your bill.

What if I do not have insurance from an employer, a Marketplace, or an individual plan? Do these new protections apply to me?

Some health insurance coverage programs already have protections against surprise medical bills. If you have coverage through Medicare, Medicaid, TRICARE, or receive care through the Indian Health Services or Veterans Health Administration, you don’t need to worry because you’re already protected against surprise medical bills from providers and facilities that participate in these programs.

What if my state has a surprise billing law?

The No Surprises Act supplements state surprise billing laws, it does not supplant them. The No Surprises Act instead creates a “floor” for consumer protections against surprise bills from out-of-network providers and related cost-sharing responsibility for patients. So as a general matter, as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state law general will apply. For example, if your state operates its own patient-provider dispute resolution process that determines appropriate payment rates for self-pay consumers and Health and Human Services (HHS) has determined that the state’s process meets or exceeds the minimum requirements under the federal patient-provider dispute resolution process, then HHS will defer to the state process and would not accept such disputes in the Federal process.

As another example, if your state has an All-Payer Model Agreement or another state law that determines payment amounts to out-of-network providers and facilities for a service, the All-Payer Model Agreement or other state law will generally determine your cost-sharing amount and the out-of-network payment rate.

Where can I learn more?

Still have questions? Visit https://www.cms.gov/nosurprises, or call the Help Desk at 1-800-985-3059 for more information. TTY users can call 1-800-985-3059.

1Health Insurance Marketplace® is a registered service mark of the US Department of Health & Human Services

Patient Portal

When you log in to our secure patient portal, you can view your health information, summaries of your office visits, test results, and patient education. You can also complete online forms, request medication refills and communicate with our clinical staff.

To register for our patient portal, simply provide us with your email address and you will receive an email containing a secure link to complete the registration process. If you do not receive an email, please call our office at (406) 721-4436 ext.5937

Medical Records Department -Call Us Directly

To obtain a copy of your medical records from our office, download and complete our Release of Information form. You can then mail it, fax it to (406) 721-6053, or bring it to our office. Your records will be available within 10 days unless previous arrangements have been made. If you have a question about obtaining your medical records, CALL our medical records department directly at (406)721-4436 ext.5937.

When to call Medical Records Directly:

A patient may call us directly when needing their medical records transferred to another provider, a workers compensation, insurance company, or themselves. We can also help with the patient portal.

A provider’s office may call us directly especially if they have a patient in the office and need to reach us in a timely manner.

An attorney’s/ insurance or workers compensation office can call us directly to check status of a patient’s appointment and/or their request for medical records.


Office Visits: If your insurance is a HMO/managed care plan then you are required to obtain a referral from your primary care physician, the referral must be obtained before you can be seen for an office visit. Please coordinate this with your primary care physician in advance. Appointments can be rescheduled if required referrals are not received in the office by the time of your visit.

Most insurance do not require a referral for a clinic visit, please contact your insurance carrier to confirm prior to your visit.

Physical Therapy: You will need a referral from your physician or medical provider (primary care doctor, nurse practitioner, orthopedic surgeon, podiatrist, chiropractor, etc.) for insurance to pay for your physical therapy treatment.

Missoula Bone & Joint will accept an initial referral by fax, by phone, or by email from your provider, and we will obtain the needed signed prescription within days of your referral, or you may bring the signed referral form with you to our office.

Refer a Patient: If you are a Provider and would like to refer a patient to Missoula Bone & Joint Clinic or Physical Therapy we have a REFER A PATIENT tab at the bottom of our home page. Please fill in the information and submit the request. Missoula Bone & Joint will call your patient within 1 business day to schedule their appointment with the appropriate provider.

Medical Refills

Prescriptions and refills for established patients of Missoula Bone & Joint are routinely handled from 8:30am-4:00pm Monday through Friday. For medication refills, please have your pharmacy fax a refill request to our office at Fax: (406) 721-6053. Please allow at least 24 hours for refill processing.

No refills are issued during the evenings, weekends, or holidays, as the doctors do not have access to your medical records during those times. It is helpful to anticipate your refill needs to avoid an interruption in your medication therapy. 

If you need a refill between office visits:

  • Please allow at least 24 hours for refill processing.
  • Call your pharmacy to request a refill. The Pharmacist will contact our office if necessary. If the request is for a narcotic, per Federal Law these cannot be called or faxed in and prescriptions must be picked up in person.
  • Refill requests are handled from 8.30am-4.00pm Monday through Friday.
  • Any medication requests after 4.00pm will be addressed the next business day.
  • Prescriptions are not refilled after hours, on weekends, or on holidays.
  • Narcotic pain medications will not be routinely prescribed for longer than 6 weeks post-operatively. Patients requiring longer term narcotic management will be referred to their primary care provider.

Cancellation Policy

Please contact our office within 24 hours of your scheduled appointment if you need to reschedule or cancel. Every time a patient does not notify us that they will be unable to keep an appointment it prohibits another patient from being able to see one of our providers.

If you do not let us know at least two hours prior to your appointment time that you will be unable to keep your scheduled appointment, you will be assessed with a "no-show." Two "no-shows" within a rolling 24-month period will result in a patient being discharged from our practice and no further appointments will be scheduled for him/her.

Hospital & Surgery Center Affiliations

Providers at Missoula Bone & Joint have hospital or surgery center affiliations with:

  • St. Patrick Hospital, Missoula
  • Missoula Bone & Joint Ambulatory Surgery Center, Missoula
  • St. Joseph Medical Center, Polson

Information for Hospital Surgical Patients

When you are having surgery at St. Patrick Hospital, please contact your surgeon's assistant to discuss arrangements for a pre-registration appointment at the hospital.

During your pre-registration appointment, you may require lab work, X-rays, and an EKG. The hospital will then send the results to your surgeon's office prior to surgery.

If you are scheduled for either a total hip replacement or total knee replacement, specific information is available at the hospital for your review.

Make sure you understand your surgery care plan before the day of surgery. 

IMPORTANT: Do not EAT or DRINK anything after MIDNIGHT the night before your surgery.

Generally, you will be asked to arrive at the hospital 2 hours prior to your scheduled surgery time. Please keep in mind road conditions during the winter months and plan appropriately. Also arrange for a responsible adult to drive you home following your surgery and have someone stay with you for at least 24 hours.

Upon discharge from the hospital, you will be provided with specific instructions given by your surgeon. At that time you will be provided with a post-operative appointment here at Missoula Bone & Joint, or you may be told to contact our office at (406) 721-4436 to schedule a time.

Please contact your surgeon's orthopedic assistant at any time regarding questions or concerns.

Total Joint Replacement Instructions(Dr. Channer Only)



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