Patient Information Name First Last Date of Birth* Month Day Year Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneEmail Address* Social Security # Primary Physician Gender Male Female Marital Status Single Married Divorced Widowed Ethnicity Hispanic or Latino Non-Hispanic or Latino Decline Race African American Asian Caucasian Chinese Filipino Japanese Native American Native Hawaiian Pacific Islander Decline Guarantor Same as Patient Name* First Last Date* Month Day Year Address* Street Address Relationship to Patient* Employment Information (Patient or Responsible Party)Employer Employer Address Occupation Employer Phone NumberConsent to Release Information and Acknowledgement of Receipt of Notice of Privacy PracticeI authorize Collins Orthopaedics & Sports Medicine, LLC to release medical information and supporting documentation contained in my medical records maintained in this office to any entity that may be financially responsible for payment of expenses related to treatment, including my insurer, health plan, Medicare, Medicare carriers, the Health Care Financing Administration and any external professional review organization acting on their behalf, for the purpose administering benefits under such plans. If my treatment is work-related, I authorize Collins Orthopaedics & Sports Medicine, LLC to release medical information regarding such treatment to my employer and/or its designee. I authorize Collins Orthopaedics & Sports Medicine, LLC to release medical records to the applicable above-listed entities that may require medical review pursuant to a quality improvement program. I hereby consent to Collins Orthopaedics & Sports Medicine, LLC using any of my protected health information for any treatment, payment or healthcare operation activity, as described in this Notice of Privacy Practices which have been made accessible to me. I authorize Collins Orthopaedics & Sports Medicine, LLC to release medical records and reports to any health care provider participating in the care rendered by Collins Orthopaedics & Sports Medicine, LLC, including but not limited to referring physicians, hospitals, home health providers or (example: Spouse and/or Family member) I CERTIFY THAT I HAVE READ THE FOREGOING FINANCIAL POLICY AGREEMENT AND CONSENT TO RELEASE INFORMATION AND THAT I UNDERSTAND THE PROVISIONS THEREIN. Name of Patient (Please Print)* Date* MM slash DD slash YYYY Signature of Responsible Party*Relationship to Patient* PhoneThis field is for validation purposes and should be left unchanged.