Patient Choice Letter

Patient Choice Letter

Patients Choice Letter

Patient Name
First Last
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Age
Provider
Incident
Office
I, as the Patient, understand that in accordance with Medicare guidelines and HIPAA regulations that I have a CHOICE to select my DURABLE MEDICAL EQUIPMENT / ORTHOTICS AND PROSTHETIC COMPANY.

I elect to use SOUTH BEACH ORTHOTICS AND PROSTHETICS, INC., to evaluate and treat me for my prosthesis.

My signature below indicates my approval of this election.
Signature
Patient Signature
Print Name
First

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