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 necessary and prescribed device(s) to be manufactured or reimbursed.

Authorization for Future Contact
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 - Cell Phone Permission
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