Patient Information
Reason for Appointment
Regulations
For Insurance purposes we are required by Federal Regulations to obtain the information below.
Person Responsible for Payment of Account
Insurance Information
Digital Signature
THIS IS NOT AN AUTHORIZATION TO RELEASE MEDICAL RECORDS. I hereby authorize Orthopaedic and Sports Medicine Center to furnish information to insurance carriers/Medicare/Medicaid concerning my illness and treatment. I assign to the physicians all payments for medical services rendered to myself or my dependents, regardless of custody arrangements.