Patient Registration Signature Form
I Name: Your Email (required)
understand there are some circumstances that may require Tony Martin Limb and Brace to contact me regarding my care. By initialing and signing below, I authorize Tony Martin Limb and Brace to contact me via Voicemail, Text or Email at the following:
We will leave voice messages, send text or email when available. If you do not want information on any of the following to be left please indicate by checking.
Billing/ Account Information
I authorize Tony Martin Limb and Brace to share information regarding my treatment or payment for treatment, with the following individuals.
Son or Daughter
I acknowledge that I have been offered a copy of the Tony Martin Limb and Brack Notice of Privacy practices, dated January 2015.
I request that payment of authorized Medicare, Medicaid or private insurance benefits be made to Tony Martin Limb and Brace for any covered services furnished by Tony Martin Limb and Brace. I agree to pay to Tony Martin Limb and Brace the deductible and/ or coinsurance on my claim.
I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services (CMS) and its agents Champus/ Tricare and its agents, or to any private insurance company any information needed to determine these benefits or the benefits payable for related service.
Is someone else signing on behalf of the patient? YesNo
Relationship to Patient
Patient Representative Name
Address of Representative
Reason for Patient's inability to Sign: