Medical Registration Form

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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.