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Registration and Medical Forms | | To the right are several forms that we ask you to complete before your appointment and/or surgery.
Please click on the link to download the appropriate pdf form as directed by your physician and/or a member of Mansfield Orthopaedics' staff.
Please bring the completed form/s with you to your scheduled visit. This will help expedite the registration process.
Note: the New Patient Welcome Packet includes the following
Patient Health History
Office Policy & Narcotic Use Contract
Payment Authorization.
Hospital Affiliation:
Copley Hospital (Mansfield Orthopaedics is a practice
of Copley Hospital)
North Country Hospital
Appointments:
Please call the office to make an appointment in advance, unless your arrangements have already been made through your primary care provider.
If you are unable to keep your appointment, kindly give 24 hours notice. We make a sincere effort to adhere to our appointment schedule and appreciate your patience if we are late due to emergencies or hospital surgery.
Insurance:
Mansfield Orthopaedics accepts most major insurance plans.
Fees & Payments:
We make every effort to help you manage the cost of your medical care.
Co-pays are expected at the time of the visit.
We request payment arrangements for all office services at the time they are rendered unless prior arrangements have been made.
We accept cash, checks, Visa, MasterCard and debit cards for your convenience.
If we are a participating provider of your insurance company, we will bill them. However, payment is the patient’s responsibility. We will help in any way we can to assist you in handling claims.
Discount and Free Medical Care Program
As a practice of Copley Hospital, you may qualify for assistance through Copley's Discount and Free Care Program. Please contact Copley Hospital's Patient Financial Services at 802-888-8336 for more information.
Prescriptions & Refills:
Please request all prescriptions and authorizations for renewals between 8:30 a.m. – 4:30 p.m. Monday through Friday.
Renewals requested at other times will be filled on extreme or emergent circumstances.
Mansfield Orthopaedics has a specific narcotic use contract that patients who require narcotic medications following surgery must complete and sign.
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