Koman Orthopedics And Sports Medicine - SPORTS

KOMAN ORTHOPEDICS & SPORTS MEDICINE 116 Westminster Pike Suite 100 Reisterstown, MD 21136 410-833-9300 fax: 855-485-4166 Surgery Facilities and Physician Ownership Disclosure *Westminster Surgery Center 826 Washington Road Suite 131 Westminster, Maryland 21157 *Timonium Surgery Center 1954 Greenspring Drive Lower Level 18 Timonium, Maryland 21093 Northwest Hospital 5401 Old Court Road ... I hereby acknowledge that I have received or have been given the opportunity to receive a copy of Koman Orthopedics and Sports Medicine Notice of Privacy Practices. I will pay to Koman Orthopedics and Sports Medicine any balance due for services rendered.

I understand that if full payment is not made on my behalf by my (insurer, legal representation, or workers compensation insurance) I will be responsible for any outstanding balance.