MID - COUNTY ORTHOPAEDIC SURGERY & SPORTS MEDICINE
PATIENT CONSENT FORM

Patient Name ____________________________________________________________________
                       Last                                                                                   First                                                     Middle Initial
SSN __________________________
1. RELEASE OF INFORMATION:
I hereby authorize my physician to release any medical information concerning my care, including copies of medical records, and/or billing information pertaining to my medical care to individuals or representatives of agencies or organizations in connection with obtaining payment of the medical services rendered to me.  I acknowledge that this authorization has no expiration date and is valid to authorize the release of medical records and billing information.
2. ASSIGNMENT OF INSURANCE BENEFITS:
In consideration of any and all medical services, care, drugs, supplies, equipment and facilities furnished by Mid-County Orthopedic Surgery & Sports Medicine, I hereby irrevocably transfer said, physicians, all insurance benefits now due and payable to me or to become due and payable to me under any insurance policy or policies, or any replacement policies there of that might be applicable.
3.  GUARANTEE OF ACCOUNT:
In consideration of any and all medical services rendered to the above named patient, I agree to pay Mid-County Orthopaedic Surgery & Sports Medicine the charges for all services ordered by physician.  If I have not followed the requirements for referral, second opinions, or pre-certification of my care, as outlined by my insurance carrier, I understand that I will be responsible for all charges that I incur.
4. MEDICARE INSURANCE BENEFITS:
I certify that the information given by me in applying for payment under TItle XVIII of the Social Security Act, is correct.  I authorize any holder of medical or other information about me to release to Healthcare Financing Administrator or its intermediaries or carries any information needed for this or a related Medicare claim.  I request that payment for each year, the remaining Co-Insurance and any other amounts which may become due.
The patient or patient's representatives certifies that he/she has read and accepted the above, where applicable to the patient's condition and status, and further certifies that he/she is the patient, or is duly authorized on behalf of the patient to execute such an agreement.
______________________________________________
Patient's signature/Person Authorized to Consent (Representative)		 Date _________________________
______________________________________________
Guarantor of Account if other than Patient (Relationship)		 Date __________________________
I hereby certify that I have witnessed the signatures of the patient and/or individual singing on behalf or for the benefit of the patient.
_________________________
Date		 ____________________________________________________
Witness