Prior to your initial visit to The Leone Center for Orthopedic Care, we recommend you fill out all of the forms listed below. 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 (click to open form, print and bring completed form with you to your appt.)
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.
Medical History Form (click to open form, print and bring completed form with you to your appt.)
The Medical History Form includes patient background, prior surgeries, and medications.
Medicare and Medicaid Signature Authorization Form (click to open form, print and bring completed form with you to your appt.)
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.
Note that you will also be asked to sign a form acknowledging that Dr. Leone has a separate surgical fee and this 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. Download