Forms & Payment

Accepts new patients

Medicare Medicaid Workers' compensation Other
Yes Yes Yes Yes

Medical insurance plans and payment options

All major insurance plans accepted. Please call (937) 208-2091 to verify.

Cash, Check, Visa, MasterCard, American Express, Discover

HIPAA Policy

HIPAA Privacy Notice & Signature Forms
Please review the HIPAA Privacy Notice and complete the signature page if this is your first visit to Wright State Orthopaedic Surgery, Sports Medicine & Rehabilitation. Mail, fax or bring this form with you to your first appointment.

Office information from Wright State Orthopaedic Surgery, Sports Medicine & Rehabilitation

Health History Form - Revised Dec 2010
Please complete this form if this is your first visit to Wright State Orthopaedic Surgery, Sports Medicine & Rehabilitation. Fax or bring this form with you to your first appointment.

Patient Information/Records Release Form
Please use this form if you need to release your medical information/records.

Patient Referral Fax Form
Physicians Offices: Please use this form to fax over your patient referrals.

Patient Registration Form
Please complete this form if this is your first visit to Wright State Orthopaedic Surgery, Sports Medicine & Rehabilitation. Mail, fax or bring this form with you to your first appointment.

Contact Information

Wright State Orthopaedic Surgery, Sports Medicine & Rehabilitation 30 E. Apple Street, Suite 2200 Dayton, OH USA 45409 View map Phone (937) 208-2091 Fax (937) 208-6141

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This website is provided by the American Academy of Orthopaedic Surgeons as a service to its members. All materials on this Web site have been created, developed or assembled by the member physician, who is solely responsible for its content and any permissions necessary to properly place the materials on this website. The AAOS does not review this information nor does it exercise editorial control over it and consequently AAOS is not liable for any damage that may be caused by this information.