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Patient Consent Form

e-sign or download and sign the PDF consent form

Completion of the consent form may be necessary for IPG to properly bill your health insurance plan.

As part of your surgery, your doctor may use a manufacturer to supply your implant device(s), biologics, and/or supplies used in your surgical procedure. IPG handles the billing and reimbursement from your health insurance plan(s) for your medical device.

You will be billed separately by IPG for your deductible and/or co-insurance and may be responsible for paying the balance based on your benefits at the time of your procedure.

For IPG to process the medical device service request and to obtain reimbursement, IPG will need specific Personal Health Information (PHI) including, but not limited to: name, address, date of birth, phone number(s), insurance information and pertinent medical information to process the claim with your health insurance plan(s).

Your healthcare provider is permitted by federal laws to release this information for payment purposes. You can revoke this authorization at any time, according to your patient rights, listed in the document.

NOTE:

Please don’t click the link to the form until you’re ready to sign. To review the form before signing, please view the PDF sample by clicking here.

Click to sign as

Patient

Click to sign as

Legal Representative

If you prefer to print and sign a PDF, Click here to download.

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Contact Us


MAILING ADDRESS
IPG-Dept. 2443
P.O. Box 122443
Dallas, TX 75312-2443

Email: contact@ipgpatient.com

Phone: (866) 295-1260

Fax: (866) 753-0194

IPG partners with your health insurance plan in an effort to lower your out-of-pocket expenses on surgical procedures.

A Few Procedures that we Cover

> Orthopedics
> Neurosurgical
> Cardiovascular
> Ophthalmology
> ENT
> Digestive
> Urological
> General Surgery

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