Johns Creek Vickery Village | New Patient Information Record

||Johns Creek Vickery Village | New Patient Information Record
Johns Creek Vickery Village | New Patient Information Record 2018-01-26T13:49:06+00:00

Johns Creek Vickery Village | New Patient Information Record

  • EMPLOYMENT INFORMATION

  • Insurance Information

  • Workers' Compensation Information

  • I hereby assign to and authorize payment to Dominion Orthopaedic LLC of all benefits payable under the terms of any insurance policy listed above. I realize the insurance, worker’s compensation and/ or liability claims may not pay the entire bill. I agree to pay the difference or the entire bill if necessary. I also agree to pay costs of collection, including attorneys.