1. I certify that the above information is the truth to the best of my knowledge.
2. I give consent to exam and treatment, by all qualified personnel at Generations, for the above named individual.
3. I hereby authorize Generations Family Health Center, Inc. to release to my insurance company any necessary information needed to file and expedite payment on my claim. I further assign any benefits payable on my behalf to Generations Family Health Center, Inc.
4. I understand I am financially responsible for any balance not covered by my insurance carrier.
5. I understand that I am responsible for any balance of payment and co-payments and they are to be paid at the time of service. (We reserve the right to refer your account to a collection agency in certain circumstances)