new_patient_form_1 new_patient_form_2 PRINT THE BLANK FORMS AND FILL OUT PRIOR TO YOUR APPOINTMENT

ORTHOPAEDIC ASSOCIATES, LLP

INSURANCE INFORMATION- PRESENT YOUR CARD TO RECEPTIONIST

POLICY OR CERT #___________________________

GROUP #_______________________________

DATE OF BIRTH___________________________

PATIENT	(NAME)_________________________________ RELATIONSHIP TO SUBSCRIBER_____________________
	DATE OF BIRTH:____________________ SOC SEC #_____________________

ADDITIONAL SUBSCRIBER	EMPLOYER	EMPLOYER ADDRESS
______________________	______________________________	_______________________________________

NAME OF INSURANCE COMPANY	____________________________	SOC SEC #_______________________
POLICY OR CERT #____________________________	GROUP #_____________________________________	DATE OF BIRTH______________________

I consent to treatment necessary for the care of the above named patient.

I authorize the release of all medical records to the referring source, primary care physician, and to my insurance company.

I allow fax transmittal of my medical records, if necessary.

I acknowledge full financial responsibility for services rendered by ORTHOPAEDIC ASSOCIATES and will promptly pay

ALL BILLS NOT COVERED BY INSURANCE UNLESS A PAYMENT PLAN IS ARRANGED

I understand that payment of charges incurred are due at the time of service unless other definite financial arrangements

have been made prior to treatment.

I agree to pay all reasonable attorney fees and collection costs in the event of default of payment of my charges.

I further authorize and request that insurance payments be made directly to ORTHOPAEDIC ASSOCIATES

LLP , should they elect to receive such payment.

I have read and fully understand the above consent for treatment, financial responsibility, release of medical information

and insurance authorization.

WAIVER

	I, (patient's name)_______________________________________	,understand	that if my insurance company
	determines that my visit(s) to this office are not covered	including any	legitimate charges for care due to

	failure of my primary care physician to put through a referral /authorization request, or any other circumstances for which
	authorization for services is denied including termination of coverage with or without my knowledge, I will be responsible for reimbursement to provider for any services rendered.

Date________________________________

Signature___________________________________________