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About You

Your Name(Required)
Your Address

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RESPONSIBLE BILLING PARTY IF DIFFERENT THAN PATIENT – NAME, DATE OF BIRTH, ADDRESS, PHONE NUMBER AND SOCIAL SECURITY NUMBER I REQUEST THAT PAYMENT(S) OF AUTHORIZED BENEFITS FROM MY INSURANCE CARRIER BE MADE ON MY BEHALF TO THE PROVIDER LISTED ON THIS FORM FOR ANY SERVICES FURNISHED TO ME BY THE PHYSICIAN. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE IT TO THE LISTED INSURER(S) AND/OR AGENTS OF THESE COMPANIES. ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS FOR OTHER RELATED SERVICE. I HEAR BY ACCEPT RESPONSBILITY FOR ANY SERVICE(S) PROVIDED TO ME THAT IS NOT COVERED BY MY INSURANCE. I AGREE TO PAY ALL COPAYS, COINSURANCE AND DEDUCTIBLE AMOUNTS AT THE TIME SERVICES ARE RENDERED. I ALSO ACCEPT RESPONSIBILITY FOR FEES THAT EXCEED THE PAYMENT MADE BY MY INSURANCE; IF GALBRAITH PODIATRY GROUP DOES NOT PARTICIPATE WITH MY INSURANCE.

new patient form

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new patient form

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Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

About You

Your Name(Required)
Your Address

Section Break

RESPONSIBLE BILLING PARTY IF DIFFERENT THAN PATIENT – NAME, DATE OF BIRTH, ADDRESS, PHONE NUMBER AND SOCIAL SECURITY NUMBER I REQUEST THAT PAYMENT(S) OF AUTHORIZED BENEFITS FROM MY INSURANCE CARRIER BE MADE ON MY BEHALF TO THE PROVIDER LISTED ON THIS FORM FOR ANY SERVICES FURNISHED TO ME BY THE PHYSICIAN. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE IT TO THE LISTED INSURER(S) AND/OR AGENTS OF THESE COMPANIES. ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS FOR OTHER RELATED SERVICE. I HEAR BY ACCEPT RESPONSBILITY FOR ANY SERVICE(S) PROVIDED TO ME THAT IS NOT COVERED BY MY INSURANCE. I AGREE TO PAY ALL COPAYS, COINSURANCE AND DEDUCTIBLE AMOUNTS AT THE TIME SERVICES ARE RENDERED. I ALSO ACCEPT RESPONSIBILITY FOR FEES THAT EXCEED THE PAYMENT MADE BY MY INSURANCE; IF GALBRAITH PODIATRY GROUP DOES NOT PARTICIPATE WITH MY INSURANCE.