Orthopaedic Surgical Associates, LLC

Available Forms

Consent Forms E-mail/Texting Consent Financial Policy HIPPA Insurance Card Upload Medical History Form New Patient Registration Form Prescription Refill Request - Updox Example Remit Payment Review of Symptoms Telehealth Consent Update Contact Information Update Insurance Information

Consent Forms

Consent for Treament

I, the undersigned hereby authorize Orthopaedic Surgical Associate providers to examine me, to administer such treatment as is necessary and to perform such procedures as are considered therapeutically or diagnostically necessary. *

For Treatment of a Minor: I hereby authorize the medical providers of Orthopaedic Surgical Associate to give my minor son/daughter treatment that he/she may need. *

Patient/Guarantor Name *

First and Last

Patient/Guarantor Signature *

Date Completed *

Consent for Involvement in Care

Unless this portion of the form is completed, we cannot talk to anyone but you regarding your medial care. If precriptions are written for you, no one other than yourself can pick them up, and we cannot speak to anyone regarding billing information on your account.

Patient Name *

First and Last

I understand and assume responsibility of notifying Orthopaedic Surgical Associates whenever the listed information changes. I understand this release excludes; insurance companies, attorneys and other health care providers. *

Date Completed *

Billing/Payment Information

I hereby authorize Orthopaedic Surgical Associates, LLC to speak to the person(s) listed below regarding my billing and payment information.

First Name

Last Name

Relationship to Patient

First Name

Last Name

Relationship to Patient

Medical and Prescription Information

I hereby authorize Orthopaedic Surgical Associates, LLC to release my medical information/records and prescriptions that need to be picked up on my behalf to the person(s) listed below.

First Name

Last Name

Relationship to Patient

First Name

Last Name

Relationship to Patient

I do not wish to provide consent to authorize any other person(s) at this time.

* Required field