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.
Contact Us
Call 954-489-4575 or fill out our
I give my highest recommendation to any patients that are looking for a “top notch” professional when they require hip replacement surgery.
Ronald Shupler
