Patient Information Form

Please correct the errors described below.

Patient Information

Employer Information

Who to contact in an emergency:

If the patient is a minor, please complete this section

Insurance Information

All Patients, Please Read & Sign

I authorize payment of medical benefits from Medicare, Medigap, private and/or group insurance be made on my behalf to Idaho Foot & Ankle for any services or supplied furnished to me. I authorize any holder of medical information about me to release to the Health Care Financing Administration or my insurance company any information needed to determine benefits for related services. I also take responsibility for payment of charges, regardless of payment or denial of payment from my insurance company.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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