Patient Advocacy Intake Form

You are entering webpages belonging to the American Association of Orthopaedic Surgeons, which includes information and resources for Association advocacy efforts and the Political Action Committee of The American Association of Orthopaedic Surgeons (OrthoPAC).

To be completed by the orthopaedic patient of an AAOS member.

Referring Orthopaedic Surgeon Name

Today's Date

Patient Name

Cell Phone Number

City

State

Congressional District

Do you have a relationship(s) with your U.S. Representative or Senator? Yes No

If yes, briefly describe the relationship

What AAOS advocacy issues have impacted your orthopaedic care? (check those that apply) Surprise medical billing caused you added financial harm or burden Your insurance company’s prior authorization requirements prevented you from having or delayed necessary surgeries causing additional health issues The recently lifted restrictions on telemedicine have contributed to a better medical outcome or better quality of care

Briefly describe your concerns or experience with this issue

I would like to be contacted about healthcare advocacy and grassroots activities and how I can assist with AAOS Advocacy efforts. Yes No

Release and Disclaimer:
I understand that AAOS may photograph and digitally record the images or voices of participants in the Patient Advocacy Program. By participating in the Program, I am authorizing AAOS to so capture my image and voice and I grant AAOS permission to use them in Program materials, including brochures, website, news articles, videos and social media posts that are developed to educate AAOS members, public and federal legislators on patient health advocacy concerns. I have no expectation of being paid for this release and disclaimer and I release AAOS, its officers, directors, employees, affiliates and agents from any liability, loss or damage resulting from my participation in the Program.

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