New Patient Form

PATIENT INFORMATION
INSURANCE INFORMATION
PROOF OF INSURANCE / ASSIGNMENT & RELEASE OF BENEFITS
Patients are required to show both proof of insurance and a Government issued photo ID at their initial and subsequent visits. The patient (or parent/legal guardian) is responsible for informing our office of any changes in your insurance coverage since your last visit. Please assure that notification is made no later than 24 hours prior to your appointment to avoid having to reschedule.

I hereby assign all medical and/or surgical benefits, to include Major Medical Benefits to which I am entitled, including Medicare, private insurance, and any other health plan to: The Orthopedic Specialty Center of Northern California.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release medical information to secure payment.
MEDICAL HISTORY
ALLERGIES
MEDICATION AND DOSAGE
REVIEW OF SYSTEMS
FAMILY HISTORY
PAIN
WALKING