Patient Forms

Once you have made an appointment with Advanced Center for Orthopedics and Plastic Surgery, you will need to fill out our patient forms. To make it more convenient for you, you may download our required patient forms, print them, and fill them out prior to your appointment at Advanced Center for Orthopedics and Plastic Surgery. Along with your completed patient forms, please bring the following with you to your scheduled appointment:

  • Insurance Card
  • Photo ID
  • Referrals (If required by your insurance)
  • Co-Payments (If required by your insurance)

Please note: You will need Adobe Acrobat Reader to view the following patient forms. You can download Acrobat Reader for free by clicking the button to the right.

All Patients

Please print and complete the Insurance Authorization patient form below:

For Drs. Benson, Blotter, Connolly, Dixon, Doppelt, Leonard, Loewen, Swentik, Taylor, Warlick (non-spine patients), and/or P.A. Asmus (non-spine patients), P.A. Blaksmith, P.A. Koski, P.A. Parks, P.A. Tourville and F.N.P. Korpi:

Please print and complete the Patient Questionnaire Initial Evaluation patient form below:

For Dr. Warlick (neck/spine patients only):

Please print and complete the Spine Questionnaire patient form below:

For Physical Therapy Patients:

Please print and complete the Physical Therapy Medical Functional Questionnaire patient form below:

For Authorization for Release of Medical Information:

  • Please complete all personal information requested.
  • Specify your attending doctor.
  • Indicate the parts of your record requested, along with dates of service (as applicable), and initial where indicated.
  • Identify requested recipient.
  • Specify date or event the authorization is to expire.
  • Read all clauses.
  • Patient or patient’s legal representative signature and date of signature.
  • Relationship to patient if other than patient signs the form.
  • Witness signature if other than patient signs the form.
  • Specify reason patient cannot sign the form.

Note: In non-emergency situations, documentation of legal authority must accompany the authorization form if anyone other than the patient signs this authorization form. Please allow up to 10 business days to complete.

Once complete, please mail the signed medical release form to:

Advanced Center for Orthopedics and Plastic Surgery
Attn: Release of Medical Information
1414 W. Fair Avenue, Suite 190
Marquette, MI 49855

OR, Fax your signed release form to Advanced Center for Orthopedics and Plastic Surgery at:

(906) 228-9371
Attn: Medical Release of Information

OR, Send the completed release form by email using the form below:

  • Please scan your completed document and save it as a PDF, which you can then submit through this form. (We can also accept jpeg and tiff format.)
    Accepted file types: pdf, jpg, jpeg, tiff.
  • This field is for validation purposes and should be left unchanged.