Patient Demographic & Insurance Information Form (Page 2 of 2) in pdf

Patient Demographic & Insurance Information Form Page 2

RELEASE AND ASSIGNMENT: I hereby consent to any necessary medical treatment for myself, child, or

the above named minor, for whom I am legally responsible. The release of medical information to any

insurance carrier, and direct payment to McCain Orthopaedic Center for any treatment or examination rendered

is authorized. I hereby acknowledge and accept final responsibility for payment of charges for medical service

rendered.

Signed ____________________________________________Date__________________

Patient Demographic & Insurance Information Form Page 2