The above information is true to the best of my knowledge. I also authorize Baker Orthotics and Prosthetics, or my insurance to release any information required to process my claims. I authorize my insurance benefits be paid directly to the physician. I Understand that I am financially responsible for any balance.
As Part of the admission process, you will be receiving information on several
policies and procedures that we have implemented to ensure your treatment while
in our care is of the highest quality. This acknowledgement indicates your receipt of
such information at the time of your initial registration or patient contact.
I hereby assign all health insurance benefits to Baker O & P for services rendered.
This assignment includes benefit programs of which I am beneficiary. I authorize the
release of all information from all sources necessary to secure payment for services
rendered. The benefits/funding outlined above have been explained to me.
I am aware and understand that this does not guarantee services will be
reimbursed as outlined. I understand that I am responsible for payment of
charges not covered by my insurance or applied to my deductible/co-pay.
I hereby attest that I am the person ( or owner of
the property if non-human subject matter) indicated on the attached photograph/
video. I freely grant Baker O & P irrevocable permission to publish this image/video,
in whole or in part and for a length of time determined by Baker O & P, on their
website or in their Annual Report or Newsletter without remuneration. I warrant
that said picture/video is free of any abuse of copyright law. I will hold harmless the
aforementioned Baker O & P from any liability by virtue of any distortion or
alteration unless it can be proven that such alterations and or distortions were done
with malicious intent.
I have read and fully understand the contents of this release. I declare that I am
over the age of 18 years, and am fully competent to sign this release on my own
I hereby Authorize the Disclosure and Release between Baker 0 & P and:
Information to be released is:
For the following dates:
I authorize release of my medical records as listed above and understand
that my authorization will remain in effect unless I cancel by written notice.