Quién le refirió? ______________________________________________

Teléfono: _______________________________

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AUTHORIZATION OF BENEFITS AND TO RELEASE INFORMATION

AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN:

I  hereby assign payment of the medical and/or major medical benefits, if any, otherwise

payable to me for services, directly to the designated physician and/or Metrolina Orthopedic

and Sports Medicine Clinic. This authorization is valid for any and all insurance claims filed

for me by Metrolina Orthopedic and Sports Medicine Clinic to any and all insurance companies

and any attorney representing me.  This authorization is valid from this date until written notice of

cancellation is received in the office of Metrolina Orthopedic and Sports Medicine Clinic.

I understand that I am financially responsible to Metrolina Orthopedic and Sports Medicine

Clinic and/or the physician for charges not covered or paid by this agreement.  I understand

that I am personally responsible for total amounts due in this office for services rendered.

AUTHORIZATION TO RELEASE INFORMATION:

I hereby authorize Metrolina Orthopedic and Sports Medicine Clinic to release any information

acquired in the course of my examination and treatment to the insurance company(ies), treating

physicians, employer, worker's compensation representative, and any attorney involved.

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Firma

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Fecha

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Para su información, nota estas polizas de la clínica:

(1)  Solicitaciones para recetas nuevas o para re-Ilenar una receta, deben hacerse antes de la 1:00,

lunes-viernes

(2)  Si hay que cancelar una cita, hazlo el día antes. Si cancelan en el día de la cita,

cobran $15.  Citas para ver el doctor o para hacer terápia física pueden ser

canceladas 24 horas al día...habla al número de la oficina.

(3)  Si uno no viene a su cita y no habla para avisarnos, hay un cargo de $20 y eso tiene que estar

pagado antes de la próxima cita.

(4)  Hay un cargo de $20-$25 para Ilenar formas de la disability (el cargo depende en el número

de páginas de la forma)