FOOT & ANKLE CLINIC OF CENTRAL NEBRASKA 620 N

ANKLE REHABILITATION USING THE HIGHPERFORMANCE ROBOTIC DEVICE IITARBOT STUDY
FOOT & ANKLE CLINIC OF CENTRAL NEBRASKA 620 N
KELTECH INCORPORATED ELECTRIC TANKLESS COMMERCIAL WATER HEATERS HL SERIES

MUSCLE STRENGTHENING EXERCISES ANKLE MUSCLE STRENGTHENING WEEK 13 SIT
SLOVAK ORTHOPAEDIC AND TRAUMATOLOGIC SOCIETY FOOT AND ANKLE SECTION
TITLE SUPPORT AND RESEARCH OFFICER RANKLEVELBAND LEVEL 2 POSITION

Sextro-Larsen Podiatry, PC

Foot & Ankle Clinic of Central Nebraska

620 N Diers Ave Suite 100 PO Box 5020

Grand Island NE 68802

Phone: 308-381-0404 Fax: 308-381-0408 Toll Free: 1-800-847-6544

Kevin J. Larsen DPM Jonathan B. Wilson DPM Amanda L. Walsh DPM


Date: ___________ Patient: ______________________________________________________________________

(First Name) (Middle Initial) (Last Name)


Social Security # _______________________ Date of Birth: _____________________ Age: ____________


Gender: Male Female Nickname: ___________


Home Address: _________________________________________________________________________________

(Street and PO Box) (City) (State) (Zip Code)

Home Phone: _____________________ Cell Phone: ______________________ Work Phone: _________________


Mailing Address: ________________________________________________________________________________

(PO Box) (City) (State) (Zip Code)


Please Circle: Married Single Widow Divorced


Parent Name if patient is under 18: __________________________________ Parent Birthdate:__________________


Patient Employer: ___________________________________________________ Work Phone: __________________

Patient Driver’s License # ______________________ Patient Pharmacy: _________________________________


INSURANCE INFORMATION:

Policy Holder’s Name:___________________________­­­_________ Birthdate:_____________ SS#:_______________


Who can we thank for this referral: __________________________________________________


Is this Workman’s compensation related? Yes No


Authorization of Benefits

I authorize the release of any medical information necessary to process this claim. I authorize payment of medical benefits to Foot and Ankle Clinic of Central Nebraska for the services described on the claim form submitted.


Patient Signature _________________________________________________________________

Medicare Signature on File and Medigap Assignment of Benefits

I request that payment of authorized Medicare benefits to Foot & Ankle Clinic of Central Nebraska for any services furnished me by that Physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services. I hereby authorize payment of my Medigap benefits to this provider for all claims filed on my behalf. This authorization applies to all services until it is revoked by me or my representative. I understand my signature below requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claims or electronically submitted claims my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the provider agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-payment and non-covered services. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier.



Patient Signature _____________________________________________________ Date _____________





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