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New Patient Demographic Form

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If yes, on the next 2 questions do not complete the section below. Do not give us insurance cards.

Responsible Party Information


Emergency Contact Information Outside the Home:

I consent to the use or disclosure of my protected health information by Orthopaedic Associates, Inc. for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills, or to conduct health care operations. I hereby guarantee payment of all charges and authorize and direct payment from any insurance company; to include but not limited to, Medicare, Medicare supplement, Medicaid, employer, attorney or their representative to be made directly to Orthopaedic Associates, Inc. in accordance with federal, state, local and carrier billing regulations and guidelines. In the event my account becomes more than 30 days past due and if referred to a collection agency, I agree to pay collection agency fees, reasonable attorney and/or court costs.

Medical forms are to be completed by medical records staff and not by the physician. Charges may apply.

PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE PRIOR TO THE APPOINTMENT. I UNDERSTAND MY CO-PAY IS DUE ON EVERY DATE OF SERVICE. IF UNABLE TO MAKE THE REQUIRED CO-PAY, I MAY BE RESCHEDULED.

If the Signature does not belong to the patient, please list your relationship: