• New/Annual Registration

  • New/Annual Registration

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  • Consent to Share Medical Information

  • On this date, I, , do hereby grant permission for my physician or his/her staff to discuss information regarding any and all treatment results to:

  • Notice of Privacy Practices

  • Financial Policy

  • The undersigned Patient or legally authorized representative ("Agent") of the Patient acknowledges that he or she personally received a copy of the Great Lakes Surgical Associates Notice of Privacy Practices on the date indicated below.

  • All Patients: Authorization to Release Information & Assignment of Benifits

    I authorize the release of any medical information necessary to process my medical service claims. I permit a copy of this authorization to be used in place of the original. I hereby authorize Great Lakes Surgical Associates (GLSA) to apply for benefits on my behalf for covered services rendered by my physician. I request that payments from my insurance company be made directly to GLSA. I certify that the information I have reported regarding my insurance coverage is correct. I understand I can revoke this authorization at any time by submitting a written request. I hereby state that all the above information is valid and accurate to the best of my knowledge.

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  • Information about Agent (attach appropriate documentation):

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