New Patient Information form

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Emergency Contact Information

Patient Employer Information

Policy Holder (Guarantor) Information

Assignment of Benefits

I hereby authorize my insurance company to pay directly to Dr. Arrington/Dr. Wade/Dr. Delpak the benefits and amount due and otherwise payable to me for their services, as described on the customary charges for those services. I acknowledge and understand that I am responsible for all of the charges for all services rendered to me or any member of my immediate family. Although I have requested the doctor to bill my insurance company in the case of surgery, I clearly understand that it is still my responsibility to make sure the bill is paid in a reasonable time. If for any reason any portion of my bill is not paid by my insurance, I further agree to make arrangements for prompt payment of the bill.

Medicare

I hereby authorize my insurance company to pay directly to Dr. Arrington/Dr. Wade/Dr. Delpak the benefits and amounts due and otherwise payable to me for their services as described, but not to exceed the reasonable customary charges for those services. I understand that I am financially responsible for all remaining charges incurred, whether or not covered by said insurance.

Authorization to Release Information

, hereby authorize Dr. Arrington/Dr. Wade/Dr. Delpak to release any information regarding medical treatment for the purpose of validating and determining benefits payable in connection with any claims.

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