Patient Forms
If you would like to make an appointment, please call us at 906-225-1321.
Once you've made an appointment, various forms are provided below that you can print and complete prior to your appointment. Doing so will help make your time to see the physician faster.
Accessing the forms requires Adobe Acrobat Reader to be loaded on your computer. (If you don't already have it, you can download Adobe Acrobat Reader for free.) The amount of time to load the forms will vary based on the type and speed of your internet connection.
ALL Patients
Please print and complete the Insurance Authorization form below. Notice of Privacy Practices brochure is available for download below:
For Drs. Pearson, Blotter, Colligan, Doppelt, Taylor, Davenport, Songer (non-spine), or PA Rutkowski, Weatherdon, or FNP Pritchett (non-spine) and PA Asmus (non-spine) patients
Please print and complete the Patient Questionnaire Initial Evaluation form below (4 pages):
For Drs. Songer (spine) or FNP Pritchett (spine) patients
Please print and complete the Pain Questionnaire below (4 pages):
For Drs. Songer scoliosis patients
Please print and complete the Pediatric Spine Patient Questionnaire below (3 pages):
For Drs. Songer pediatric scoliosis/spine patients
Please print and complete the Pediatric Spine Patient Questionnaire below (1 page):
For physical therapy patients
Please print and complete the Physical Therapy Medical Functional Questionnaire below (2 pages):
Authorization for Release of Medical Information
The Authorization for Release of Medical Information form once completed and signed by you (or your legal representative), authorizes our office to release all or a specified part of your medical record to a specified recipient indicated on your form. When completing the form:
- Please complete all personal information requested.
- Specify your Attending Physician
- 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.
- 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 mail the signed form to:
Orthopaedic Surgery Associates of Marquette, P.C.
Attn: Release of Medical Information
1414 W. Fair Avenue, Suite 190
Marquette, MI 49855
OR
Fax your signed form to 906-228-9371, Attention: Medical Release of Information
Please allow up to 10 working days to process your request.
