(317) 920-7432 | Online Registration

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Registration Form
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Next of Kin


Employment


Spouse Information


Parent/Financial Responsibility/Guarantor


Medical Insurance Information


Referring or Family Physician


Medical History


General


Skin


Eyes, ears, nose, throat (HEENT)


Lungs (Respiratory)


Heart and blood vessels(Cardiovascular)


Digestive system (Gastrointestinal)


Kidneys and urine


Musculoskeletal


Nervous System


Mood and psychological


Endocrine system


Blood (Hematology)


Accident Information
Online Patient Registration

Agreement
THE UNDERSIGNED PATIENT OR OTHER RESPONSIBLE PARTY (whether or not more than one) ACKNOWLEDGES RESPONSIBILITY AND AGREES TO PAY FOR ALL SERVICES PROVIDED TO THE PATIENT BY ATLAS ORTHOPEDICS AND SPORTS MEDICINE, INC. (ATLAS) I hereby agree to fully pay for the services provided within three (3) months from this date or have a payment plan established, regardless of insurance coverage and/or any cause of action I might have against any other person or entity concerning the services rendered, and notwithstanding the assignments I have made below. To the extent of my charges incurred, I hereby irrevocably assign to Atlas, its successors and assigns, all benefits payable to me and claims I have as a result of the "accident" described above, including insurance payments, Workers Compensation payments, and monies recovered in any legal proceeding. This assignment does not release me from my responsibility to pay Atlas as I have agreed herein above. I further direct and authorize my attorney(s) named above and his/her successor(s) to pay to Atlas any money in his/her possession payable to me as a result of the accident to the extent of my charges incurred. I authorize Atlas to send said attorney(s) a copy of this Agreement and a statement of the amounts payable by me to Atlas. I authorize Atlas to periodically request from my attorney(s) and authorize and direct my attorney(s) to timely respond to Atlas request for status reports on my claims which I have assigned to Atlas. I further authorize Atlas to send this Agreement to any insurance carrier(s) who might pay me benefits which I have assigned to Atlas. In the event I do not comply with this Agreement, I will pay all fees and expenses (including reasonable attorney fees, court costs, and/or collection agency fees) incurred by Atlas to enforce this agreement.

Insurance Release Form
YOUR SIGNATURE IS NECESSARY FOR US TO PROCESS ANY INSURANCE CLAIMS AND TO ENSURE PAYMENT OF SERVICES RENDERED. The Non-Medicare Patient I authorize the release of all medical information necessary to process this claim and that is pertinent to my medical care. I understand these records may contain information from other health care providers as well as information which is administrative in nature. I specifically consent to the release of any information contained in the medical record which may relate to infection with Human Immunodeficiency Virus (HIV), AIDS, or related conditions. I assign all medical and/or surgical benefits, including major medical benefits to which I am entitled, to Atlas Orthopedics and Sports Medicine, Inc. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. The Medicare Patient I authorize the release of all medical information necessary to process this claim and that is pertinent to my medical care. I understand these records may contain information from other health care providers as well as information which is administrative in nature. I specifically consent to the release of any information contained in the medical record which may relate to infection with Human Immunodeficiency Virus (HIV), AIDS, or related conditions. I request that payment of authorized Medicare benefits be made to me or on my behalf to Atlas Orthopedics and Sports Medicine, Inc. for any services furnished me by that provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine benefits or the benefits payable for related services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.