Registration Valley Orthopedic Technology – Registration InformationPlease enable JavaScript in your browser to complete this form.1Patient Information2Referring Physician 3Subscriber Information 4Insurance Information5SignatureValley Orthopedic Technology – Registration InformationPatient InformationPatient Name *DOB *AgeSex *MFMarital StatusAddress *City, st Zip *Tel *Alt TelAlt Tel typeEmail *Spouse or Parent NameTel NextReferring Physician Tel NextSubscriber Information Same as aboveYesInsured's NameRelationship to PatientSpouseParentOtherOtherNextPrimary Insurance Information Primary Insurance Company Name *Tel Group#Insurance ID# *Secondary Insurance Information Secondary Insurance Company NameTel Group# Insurance ID#Next.I request that payment of authorized Medicare, Medicaid, or private insurance benefits be made to Valley Orthopedic Technology for any services provided to me by Valley Orthopedic Technology. I hereby assign, transfer, and set over to Valley Orthopedic Technology all of my rights, title, and interest of my medical reimbursement benefits under my insurance policy for services provided to me by Valley Orthopedic Technology. I authorize any holder of medical information about me to be released to determine these benefits. I understand that I am financially responsible for all charges whether or not they are covered by my Insurance. I have read the financial policy presented to me and posted in the waiting room and agree to this financial policy.Signature of patient or responsible party * Clear Signature Date *.The 'Notice of Privacy Practices" is available in the office for my viewing. With my Consent, Valley Orthopedic Technology may use and disclose Protected Health Information (PHI) in order to carry out treatment, payment and health care operations. With my consent, this office may also call my home and leave a message; send reminders/requests for appointment by mail; speak to other members of my household by telephone.Signature of patient or responsible party * Clear Signature Date *Signatory' Name *Submit
