Sports Physical Intake Form

Please correct the errors described below.

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

(Enter name of person FINANCIALLY responsible for your account)

INSURANCE COMPANY – INCLUDING MEDICAID

Assignment and Release

I authorize my insurance benefits to be paid directly to PanCare Health. I also authorize PanCare Health to release any information required to process this claim.

Consent for Treatment

I hereby authorize PanCare Health, its facilities and treatment centers, its affiliated physicians, dentists, ARNPs, physician assistants and other medical personnel to administer examinations and treatments as deemed medically necessary.

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