Assignment Of Benefits, Direction To Pay And Release Of Information Form (Page 2 of 3) in pdf

Assignment Of Benefits, Direction To Pay And Release Of Information Form Page 2

SOUTHWEST ORTHOPEDIC GROUP, L.L.P.

COMMUNICATION for TEST RESULTS

NOTICE TO PATIENT:

In order for our practice to respond promptly and accurately to your needs, use this form to

make a request of how you would like to receive TEST RESULTS. Check one:

o I will receive my results in person at your facility.

o You may call me at the following number: ________________________

o You may leave a voicemail stating for me to call your facility (Results will NOT

be left on voicemail).

o You may mail the results to: _______________________________

_______________________________

o Other: ______________________________________________________

Please list any person(s) whom you would like to have access to your medical information:

________________________________________________

For certain test results, our physicians may request that you return to the facility for a second visit and follow-up

care.

PRINT NAME: _______________________________________________________

SIGNATURE: _______________________________________DATE: ___________

Assignment Of Benefits, Direction To Pay And Release Of Information Form Page 2