1.PATIENT INFORMATION (* indicates required field)
    *Social Security # of patient
    *Patient's Date of Birth

    *First Name
    *Last Name
    MI

    Patient's Address:
    *Street
    *City
    County
    *State
    *Zip
    *Home Phone:
    Work Phone (Parents work phone if minor):
    Cell Phone #:

    Marital Status:
    *Email Address:
    *Sex:
    *Height:
    *Weight:

    Parent/Legal Guardian/Spouse:
    Parent/Legal Guardian/Spouse SS#
    Parent/Legal Guardian/Spouse Date of Birth:

    Employer:
    Business Address:
    Employer Phone:
    *Prescribing Physician:
    Diagnosis:
    Date of Onset/Injury:
    Diabetic Treating Physician:

    2. INSURANCE INFORMATION (* indicates required field)
    *PRIMARY Insurance Carrier:
    Group Name/#
    *Certificate or ID#:
    Policy Holder's Name:
    Policy Holder's SS#:
    Policy Holder's DOB:
    Relationship to patient:

    SECONDARY Insurance Carrier
    Group Name/#
    Certificate or ID#:
    Policy Holder's Name:
    Policy Holder's SS#:
    Policy Holder's DOB
    Policy Holder's Relationship to patient:

    Authorization to Release Information to Necessary vendor/insurers to manufacture or bill required device.
    I hereby authorize CREATIVE PROSTHETICS & ORTHOTICS, LLC to release only necessary information, including photographs, about me (patient) in order for my prescribed device(s) to be manufactured or reimbursed.

    Authorization for Future Contact - Cell Phone/Email Permission
    I hereby authorize CREATIVE PROSTHETICS & ORTHOTICS, LLC to contact me at any time in the future to provide me with additional information to enhance the fit and function of my orthotic/prosthetic devices and treatment.

    Authorization To Pay Benefits To CREATIVE P&O/ Authorization to Release Information
    I hereby authorize payment directly to CREATIVE PROSTHETICS & ORTHOTICS, LLC for any services I receive during my treatment. I give permission to CREATIVE PROSTHETICS & ORTHOTICS, LLC to release any information to my insurance company, attorney, assignees and/or beneficiaries.

    Financial Responsibility
    The undersigned guarantees payment to CREATIVE PROSTHETICS & ORTHOTICS, LLC for services rendered in the event insurance does not cover all fees. I am responsible for payment if the insurance carrier decides this is a noncovered service or requires pre-authorization, which I did not obtain. *Permission hereby is granted to call my cell phone number.

    MEDICARE PATIENTS:
    I HAVE RECEIVED COPY (OR NOTICE) OF THE SUPPLIER STANDARDS