Patient Forms

Prior to your initial visit to The Leone Center for Orthopedic Care, we recommend you fill out both the Holy Cross Patient Information Record Form and Medicare and Medicaid Signature Authorization Form. Doing so in advance of your first appointment will ensure that our records department has the information they need to make your experience at The Center as smooth as possible.

Holy Cross Patient Information Record Form

The Holy Cross Patient Information Record provides the hospital with basic information, including name, contact information, whether or not your condition is accident related and insurance information.

Click here to download the Holy Cross Patient Information Record Form

Medicare and Medicaid Signature Authorization Form

The Medicare and Medicaid Signature Authorization Form authorizes the release of information and payment requests necessary to process all eligible Medicare and Medicaid claims related to your hospital stay.

Click here to download the Medicare and Medicaid Signature Authorization Form

Note that you will also be asked to sign a form acknowledging that Dr. Leone has opted out of Medicare and his surgical fee will be your responsibility. The ancillary costs of your pre-surgical treatment, hospital stay and post-surgery rehabilitation and equipment are still covered by Medicare and other insurers.

Fee Acknowledgement Notice for Medicare Patients

The Leone Center for Orthopedic Care is a Holy Cross Hospital-based Medical Facility. We are therefore obligated to abide by the CMS (Center for Medicare Services) guidelines and regulations. CMS has determined that facility related charges are separate from professional fee charges. The charges quoted in this office are for fees related to William Leone, MD professional services only, and will not be billed to Medicare. All CMS Facility related charges must be billed at each visit.

Click here to download the Fee Acknowledgement Notice for Medicare Patients

 

Call 954-489-4575 or Email Us

Please do not send protected health information (PHI) through this email address. Do send your name and contact information, along with a general description of your concern so that we may follow up with you to discuss the issue in more detail.