1. PATIENT INFORMATION

TODAY’S DATE:

2. PLEASE COMPLETE THIS SECTION IF SOMEONE OTHER THAN
PATIENT IS RESPONSIBLE FOR SERVICES

3. WORKER’S COMPENSATION

4. ASSIGNMENT OF BENEFITS AND RELEASE OF INFORMATION

I, the undersigned, have insurance with and assign directly to Fountain Orthotics and Prosthetics, Inc. all medical benefits, if any, otherwise payable to me for service rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Fountain Orthotics and Prosthetics, Inc. to access/obtain/release any medical information/records on file necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

5. WAIVER FORM

I, understand that my eligibility for coverage by cannot be determined at this time. I wish to receive medical services from Fountain Orthotics and Prosthetics. If it is determined that I am not eligible for coverage, I understand that I will be responsible for payment of all services provided.

MEDICAL RECORDS RELEASE FORM

I authorize the release of my confidential health information by releasing a copy of my
medical records to
Fountain Orthotics & Prosthetics.


For Office Use Only

Fountain Orthotics & Prosthetics is requesting the following documents:

ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES

This form will be retained in your medical record

By my signature below I, , acknowledge that I received a copy of the Notice of Privacy Practices for Fountain Orthotics & Prosthetics, Inc.

I hereby designate the following individual(s) to receive communications from Fountain Orthotics & Prosthetics, Inc. that may include health information about me:


If this acknowledgement is signed by a personal representative, complete the following:

I authorize Fountain Orthotics and Prosthetics, Inc. to leave voice mail messages concerning my health information at the following number:

Signature

Please use your mouse and right click while signing, if you are on mobile please use your finger.


Signature of Insured/Guardian

*This signature will be used to verify identity with regards to PHI (Protected Health Information)


For Office Use Only

I attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Insurance Information

Fountain Orthotics and Prosthetics is requesting that you provide ALL insurance information and insurance cards at the time of service.

It is your responsibility to provide complete insurance information so that Fountain Orthotics and Prosthetics may bill your insurance(s) on your behalf. Failure to provide this information may result in you, and /or the member, being financially responsible for any and all outstanding balance(s) due.

Fountain Orthotics and Prosthetics is not responsible for any failure on your part to provide any and all correct and current insurance information. It is unlawful for Fountain Orthotics and Prosthetics to “back date” your date of service; therefore, it is imperative that you provide all necessary information no later than by your final fitting appointment.

Please understand that insurance companies base its decisions upon the dates of service as well as timely filing, so it is imperative that all insurance information is correct, current, up to date and complete. Thank you for your cooperation and assistance.

I fully understand and acknowledge the term and provisions regarding my responsibility as stated above.

Photo Release

Acknowledgement of Financial Responsibility Form