Medical Registration Form

  • Home
  • Medical Registration Form

Medical Registration Form



Cutting Edge Foot And Ankle Clinic

BILLING INFORMATION

RESPONSIBLE PARTY FOR MINOR CHILD

EXTENDED AUTHORIZATIONS

I hereby authorize Cutting Edge Foot and Ankle Clinic to furnish information to insurance carriers concerning my illness and treatments and I hereby assign to Cutting Edge Foot and Ankle Clinic all payments for medical services rendered to myself or my dependents. I am aware that it is my obligation to know my insurance company's policies and that I am responsible for payment if I have not fulfilled their requirements. I also acknowledge the receipt of HIPPA privacy policy.

CONSENT FOR TREATMENT

I hereby request and voluntarily consent to such office care, including routine diagnostic procedures and medical
treatment as may be deemed necessary by Cutting Edge Foot and Ankle Clinic and/or his designees.