Patient Choice Letter

Patient Choice Letter

Patients Choice Letter

  • MM slash DD slash YYYY
  • 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

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