Name _______________________________________ Date ___________________

Address _____________________________________________________________

City ________________________ State _________________ Zip ______________

Home Phone _____________ Work Phone _____________ Cell Phone _________

Social Security Number ______________________ Date of Birth ______________

Employer __________________________________ Occupation ______________

Business Address ______________________ State ____________ Zip ________

Pharmacy _______________________ Location ___________________________

Family Physician ____________________________________________________

RESPONSIBLE PARTY

Name of person responsible for this account ______________________________

Relationship to Patient _____________ Address ___________________________

Employer ______________ Work Phone _____________ Home Phone _________

Social Security Number ______________________ Date of Birth ______________

I authorize the release of any information including diagnosis and records of my treatment or examination rendered to me or my child during the period of such care to third party payors and or health practitioners. I authorize and request my insurance company to pay directly to the Doctors' group insurance benefits otherwise payable to me. I understand my insurance carrier may pay less than the actual bill for service. I agree to be responsible for payment of all services on my behalf or my dependents.

X___________________________________________ Date ____________________
Signature of Patient or Parent, if Minor

MEDICARE AUTHORIZATION

I request that payment of authorized Medicare benefits to be made either to me or on my behalf to Kent Foot and Ankle Center for any services furnished by them. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand that my signature requests that payment be made and authorize release of any medical information necessary to pay the claim. If "other health insurance" is indicated in item 9 of the HCFA-1500 form or elsewhere on the approved claim forms or electronically submitted claim, my signature authorizes releasing of the information to the insurer or agent shown. In Medicare assigned cases, the physician, or supplier agrees to accept the charges determined of the Medicare carrier as the full charge, and the patient is responsible for only the deductible, coinsurance, and non-covered services. Coinsurance and deductible are based upon the charge determined of the Medicare carrier.

X___________________________________________ Date ____________________
Signature of Beneficiary