Patient Intake Form

If you are a new patient to Lawall, please complete the form below.

Emergency Contact

Physician Information

Medical Device History

Hae You Ever Received an Orthotic or Prosthetic Device
Do you have any known allergies to Latex, wool, or other materials?
Is this related to a work or auto injury?

Responsible Party

Insurance Information

If patient is considered a child or spouse on the insurance plan, please complete the following:

If patient is considered a child or spouse on the insurance plan, please complete the following:

ASSIGNMENT OF BENEFITS/AUTHORITY FOR RELEASE OF INFORMATION:

I request that payment of authorized Medicare, Medicaid, or private insurance benefits be made to Lawall for any covered services furnished to me by this facility. I authorize the release of any information necessary to provide services or process claims. Even though your insurance company authorizes services, an authorization is not a guarantee of payment. As the responsible party I understand that I am personally responsible for the entire amount of my claim and that insurance benefits may be limited or non-existent. I agree to notify Lawall immediately of any change in insurance coverage or status. The date of service that will be billed to your insurance company is the date the device. is received.