This information is confidential. If we do not sincerely believe your problem will respond favorably, we will not be able to
accept your case. We will refer you to disciplines that we believe will help you. In order for us to understand your health
problems, please complete this form neatly, accurately, and completely. Thank You.
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. Furthermore, I understand that the Doctor's Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate, any fees for professional services rendered me will be immediately due and payable.
I here by authorize the Doctor to treat my condition as he or she deems appropriate. It is understood and agreed the amount paid the Doctor, for X-rays, is for examination only and the X-ray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred
at this office.
Consent to the Use and / or Disclosure of Health Information for Treatment,Payment or Healthcare Operations.
I understood if i wish to obtain a copy of the office's Nootice of Privacy Practices, that provides a more complete description of information uses and/or disclosures, one will be made available for me. I understand that i have a right to review the notice prior to signing this consent. I understand that this office reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised Notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that this office is not required to agree to yjr restrictions requested. I understand that i may revoke this consent in writing, except that for actions taken by this office in relying on such information.
I understand and authorize, that at times it will be necessary for this office to call my home or place of business and leave messages on answering machines, voicemail or E-mail.
I fully understand and accept the terms of this consent.