Authorization for Orthopedic Treatment and Procedures

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: _____________________

Consent for Treatment

I, the undersigned patient/legal representative, hereby authorize [Practice Name] and its medical providers to provide orthopedic evaluation, treatment, and procedures deemed necessary or advisable for my care. This may include but is not limited to:

• Physical examinations and evaluations
• Diagnostic imaging (X-rays, MRI, CT scans)
• Administration of medications
• Joint injections and aspirations
• Cast application and removal
• Minor surgical procedures

Financial Agreement

I understand that:

• I am financially responsible for all charges whether covered by insurance or not
• Co-payments are due at the time of service
• Insurance verification is not a guarantee of payment

Release of Information

I authorize the release of medical information necessary to:

1. Process insurance claims
2. Coordinate care with other healthcare providers
3. Comply with legal requirements

Acknowledgment

I have read and understand this authorization. I have had the opportunity to ask questions, and my questions have been answered satisfactorily.

Patient/Guardian Signature: _________________ Date: __________

Witness Signature: _________________________ Date: __________

Office Use Only

Form received by: _________________________ Date: __________ Scanned to EMR: ☐ Yes ☐ No