Atlanta Riverdale Patient Information

||Atlanta Riverdale Patient Information
Atlanta Riverdale Patient Information 2018-01-26T13:49:06+00:00
  • Dominion Orthopedic Clinic

  • PATIENT INFORMATION

  • GUARANTOR INFORMATION

  • INSURANCE INFORMATION

  • ADDITIONAL INFORMATION

  • COMPLETE INFORMATION BELOW IF APPLICABLE

  • Authorization To Pay Benefits To Physician: I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to myself or Dominion Orthopedic Clinic when they accept assignment.

    Authorization To Release Medical Information. I hereby authorize Dominion Orthopedic Clinic to release any information necessary for my course of treatment.