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Patient Forms

View/print the following forms to help with your registration and visits at Xcel Sports Medicine.

Patient Registration / Insurance Information

Complete all sections as appropriate. If the patient is 18 or younger, a parent or guardian is responsible for signing the consent for treatment section. The second page is necessary to properly bill insurance providers. The information applies to the patient AND the primary insured as indicated on the card.

• Patient Registration Form

Medical History

Complete all sections as appropriate.

• Medical History Form

Health Information Portability and Privacy Act(HIPPA) Form

The following documents outline the HIPPA Compliance Plan of Xcel Sports Medicine. The Notice of Health Information Practice Policy is information that you can review as it applies to your situation. Please print the Consent to Use and Disclose form and bring it with you.

• HIPPA Consent to Use and Disclosure
• HIPPA Policy (Patient Copy)

Billing and Cancellation Policy Information Form

The following documents outline the Xcel Billing and Appointment Cancellation Policy. This is information that you can review as it applies to your situation.

• Billing and Cancellation Policy

Liability Waiver

The liability waiver is required for activities that utilize the Pilates and exercise equipment areas of the facility. Complete and sign.

• Facility Use Liability Waiver