New Patient Registration Form Patient Details

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New Patient Registration Form Contact Information

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  •  OK to leave a message
  •  Myself
  •  Spouse
  •  Other
  •  anyone answering phone
  •  do NOT leave message

New Patient Registration Form Emergency Contact Information

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New Patient Registration Form Primary Insurance Information

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New Patient Registration Form Secondary insurance Information

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New Patient Registration Form Authorization

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I consent to all medical care, examinations, and tests determined to be necessary for me. Though I expect the care given to meet customary standards, I understand that there are no guarantees concerning the results of my care. If I refuse treatment that is suggested for me, I will not hold Range Foot and Ankle or any individual responsible for any of the consequences. I understand that I am being established by Range Foot and Ankle as a recurring patient to be provided a series of ongoing services based on my provider's orders.

I give permission to Range Foot and Ankle to take photographs for medical and/or teaching purposes. No personal identifications will be revealed.

I hereby acknowledge that I have been offered a copy of the Range Foot and Ankle Notice of Privacy Practices.

ASSIGNMENT OF BENEFITS: I hereby assign all medical benefits to which I am entitled to Range Foot and Ankle. This applies for all insurance carriers, including Medicare, private insurances and any other health/medical plans. This form will be kept on file. I understand that it is my responsibility to report any changes in insurance coverage. I also understand that it is my responsibility to know my insurance policy, and I am fully responsible in obtaining any referrals that may be required PRIOR to my appointment with Range Foot and Ankle. I understand that if a required referral is not obtained, I will take full responsibility in the payment for any unpaid fees. I authorize the release of any medical or pertinent information necessary to obtain these benefits to my insurance carrier, or any other medical entity for the continued medical care. I understand that I am financially responsible for any amount not covered by insurance and that past due accounts will be charged a rate of $10.00 per month and that all past due accounts are subject to collection proceedings.  I also understand and agree that if I am in default of this agreement, I will pay all reasonable legal fees, court costs, and any other cost necessary to collect the debt, including but not limited to fees charged by a collection agency.

I have read all of the above and agree

(Please click below to sign)
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