MEDICAL INFORMATION RELEASE FORM

PATIENT INFORMATION

Patient First Name

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Patient Middle Name

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Patient Last Name

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ADDRESS:

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ZIP CODE:

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CITY:

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STATE:

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HOME PHONE #:

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CELL PHONE #:

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SECONDARY PHONE #:

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Race:

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Ethnicity:

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DATE OF BIRTH:

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SOCIAL SECURITY NUMBER:

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MARITAL STATUS:

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PATIENT RELATIONSHIP TO THE RESPONSIBLE PARTY:

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SEX:

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PRIMARY CARE PHYSICIAN:

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REFERRED BY:

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PATIENT'S EMPLOYER INFORMATION:

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COMPANY:

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CITY:

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PHONE #:

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RESPONSIBLE (OR INSURED) PARTY INFORMATION

RESPONSIBLE PARTY NAME (LAST, FIRST, MIDDLE):

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ADDRESS:

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SEX:

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HOME PHONE #:

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WORK PHONE #:

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SOCIAL SECURITY NUMBER:

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PATIENT'S EMPLOYER INFORMATION:

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COMPANY:

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CITY:

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PHONE #:

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INSURANCE INFORMATION

PRIMARY INSURANCE COMPANY:

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ADDRESS:

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PHONE:

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CONTRACT (ID#) NUMBER:

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SUBSCRIBER'S NAME:

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PATIENT RELATIONSHIP TO SUBSCRIBER:

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GROUP NAME:

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GROUP NUMBER:

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COPAYMENT AMOUNT: $

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INSURED'S DATE OF BIRTH:

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SECONDARY INSURANCE COMPANY:

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ADDRESS:

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PHONE:

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CONTRACT (ID#) NUMBER:

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SUBSCRIBER'S NAME:

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PATIENT RELATIONSHIP TO SUBSCRIBER:

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GROUP NAME:

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GROUP NUMBER:

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COPAYMENT AMOUNT: $

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INSURED'S DATE OF BIRTH:

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MEDICAL INFORMATION RELEASE FORM

NAME:

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Release of Information

I authorize the release of information including the diagnosis, records, examination rendered to me and the claims information. This information may be released to:

Spouse

Child (ren)

Other

Information is not to be released to anyone.

This Release of information will remain in effect until terminated by me in writing.

Messages

Please call

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CELL PHONE #:

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If unable to reach me

you may leave a detailed message

please leave a message asking me to return your call

Message:

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The best time to reach me is (day)

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between (time)

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date:

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Witness:

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WE APPRECIATE THE OPPORTUNITY OF SERVING YOU.

I AUTHORIZE THE RELEASE AND DISCLOSURE OF ANY OR ALL OF MY MEDICAL AND TREATMENT RECORDS OR REPORTS TO ANY OTHER HEALTH CARE PROVIDER WHO MAY BE OF ASSISTANCE, IN THE OPINION OF Tuscaloosa Orthopedic and Joint Institute, LLC, AND/OR FOR ASSISTING IN ANY REIMBURSEMENT OR MEDICAL BENEFITS TO WHICH PATIENT MAY BE ENTITLED. I ALLOW FAX TRANSMI I 1AL OF MY MEDICAL RECORDS, IF NECESSARY. I FURTHER AUTHORIZE AND REQUEST THAT INSURANCE PAYMENTS BE MADE DIRECTLY TO Tuscaloosa Orthopedic and Joint Institute, LLC, MD, PC SHOULD THEY ELECT TO RECEIVE SUCH PAYMENT. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. A PHOTOCOPY OF THIS ASSIGNMENT SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL.

I ACKNOWLEDGE FULL FINANCIAL RESPONSIBILITY FOR SERVICES RENDERED BY Tuscaloosa Orthopedic and Joint Institute, LLC, MD, PC. I UNDERSTAND THAT PAYMENT OF CHARGES INCURRED IS 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 AUTHORIZE TREATMENT BY Tuscaloosa Orthopedic and Joint Institute, LLC, MD, PC, PHYSICIANS AND PERSONNEL.

I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT FOR TREATMENT, FINANCIAL RESPONSIBILITY, RELEASE OF MEDICAL INFORMATION AND INSURANCE AUTHORIZATION. THIS AUTHORIZATION IS VALID FOR ONE YEAR.

I have read the above and accept financial responsibility in full for this account.

SIGNED by Patient, Parent, or Guardian:

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IN CASE OF EMERGENCY PLEASE CONTACT:

PHONE:

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RELATIONSHIP:

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ADDRESS:

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