AUTHORIZATION TO TREAT: I hereby authorize the healthcare providers at this practice to perform diagnostic procedures and treatments that may be necessary for my care or the care of my minor child/ward. I understand that no guarantee has been made as to the results of examination or treatment.
FINANCIAL RESPONSIBILITY: I understand that payment for services is due at the time services are rendered unless other arrangements have been made. I acknowledge that I am financially responsible for all charges whether or not covered by insurance.
INSURANCE BILLING: I consent to the billing of my insurance company for services rendered. I understand that I am responsible for deductibles, co-payments, and any services not covered by my insurance plan.
RELEASE OF INFORMATION: I authorize the release of medical and billing information necessary to process insurance claims and for the collection of outstanding balances.
COLLECTION ACTIONS: I understand that if payment is not received in a timely manner, collection actions may be initiated, and I may be responsible for collection costs and legal fees.
HIPAA ACKNOWLEDGMENT: I acknowledge that I have received and understand the Notice of Privacy Practices regarding the use and disclosure of my protected health information.