WE APPRECIATE THE OPPORTUNITY TO SERVE YOU, AND WE PLEDGE TO GIVE YOU OUR VERY BEST MEDICAL CARE.

OFFICE POLICY ON PAYMENT:
It is our policy to require payment of all office charges at the time they are given, unless prior arrangements have been specifically made.

INSURANCE POLICY:
Insurance provides for your reimbursement on allowed medical charges. As a courtesy to you we will be happy to submit claims to most insurance carriers, if you have provided us with policy numbers, address, place of employment and any other pertinent information. You are responsible for all co-pays, co-insurance, deductibles and charges not covered by insurance. Please understand that we cannot, as a third party, become involved in prolonged insurance negotiations; this is your responsibility.
I authorize insurance benefits/payments to be paid directly to the provider. I also authorize the release of any medical information necessary to process any claims. I permit a copy of the authorization to be used in place of the original. This authorization may be revoked by either me or my insurance company at any time in writing.

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS:
I authorize the provider to release any medical information including diagnosis, test results, reports and records pertaining to any treatment or examination rendered to me. I understand that this medical information may be used for any of the following purposes: diagnostic, insurance, legal, and at times when the provider deems it necessary in order to ensure the best medical care on my behalf. I further understand that any person(s) that receive these medical records will not release any of the medical information obtained by this authorization to any other person or organization without a further authorization signed by me for release of the information.

I have read the above and accept financial responsibility in full for this account.