I give SRT Prosthetics & Orthotics permission to call and follow-up for up to 15 months after receiving my device. I hereby certify that the above information is true and correct to the best of my knowledge. I authorize SRT Prosthetics & Orthotics to utilize this information for billing and patient record purposes. I understand that I am financially responsible for my deductible, co-insurance, and items not covered by my insurance.
Please list any other party that may discuss your Protected Health Information with SRT staff.