Patient General Consent Form

Patient First Name

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Patient Last Name

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Patient Signature

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Date:

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Person other than patient

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Relationship to Patient

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Assignment of Benefits and Guarantee of Account: In consideration of all services and supplies provided by Tuscaloosa Orthopedic & Joint Institute, LLC, I understand and agree that I have full responsibility to pay Tuscaloosa Orthopedic & Joint Institute, LLC. I understand that the charges not covered by my insurance remain my responsibility and assign insurance benefits to Tuscaloosa Orthopedic & Joint Institute, LLC. I accept full financial responsibility for the immediate payment of any charges not covered by my insurance. I accept the fees charged as a legal and lawful debt and agree to pay said fee. I agree to reimburse Tuscaloosa Orthopedic & Joint Institute, LLC the fees of any collection agency, which may be based on a percentage at a maximum of 33% of the debt, and all costs and expenses, including reasonable attorneys' fees, we incur in such collection efforts.

I agree, in order for Tuscaloosa Orthopedic & Joint Institute, LLC to coordinate my care, service my account or to collect monies I may owe, Tuscaloosa Orthopedic & .Joint Institute, LLC and or their agents may contact me by telephone at any telephone inunber associated with my account, including my wireless telephone numbers, which could result in charges. Tuscaloosa Orthopedic & Joint institute, LLC may also contact me by sending text messages or mails, using any e-mail address I provide. Methods of contacting may include prerecorded or artificial voice messages and or use of autorilatic dialing devices, as applicable.

Patient Signature

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Date:

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Person other than patient

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Relationship to Patient

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Notice of Privacy Practices Receipt: I have received the Notice of Privacy Practices provided by Tuscaloosa Orthopedic & Joint Institute, LLC.

Patient Signature

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Date:

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Person other than patient

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Relationship to Patient

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