Amherst Office ~ 17 Research Dr., Amherst, MA 01002

Northampton Office ~ 6 Hatfield Street Northampton, MA 01060

413-549-8400 (p) ~ 413-549-8409 (f)

www.atkinsonfamilypractice.com

I am enrolled in the following insurance plan(s):

I acknowledge that I have voluntarily sought the services of Katherine Atkinson’s M.D. P.C, a participating provider. I accept full responsibility for paying for services provided by Katherine Atkinson’s M.D. P.C. I understand that my insurer will not pay the provider nor reimburse me for the cost of services rendered here, or for any subsequent or ancillary services which the provider may order on my behalf, if this insurance is not truly in effect or if the provider is not considered my primary care physician. I further acknowledge that it is my responsibility and not the provider’s to know what services are covered by my insurer. I accept full responsibility for paying for services provided if they are not covered by my insurance. If the above information changes at any point, it is my responsibility to notify Atkinson Family Practice.

ASSIGNMENT AND RELEASE

I certify that I and/or my dependents assign our insurance benefits directly to Katherine J Atkinson MD, PC. I understand that I am financially responsible for all charges whether or not they are paid by the insurance company. I authorize the use of my signature on all insurance submissions. I certify that Katherine J. Atkinson MD, PC and its employees have the right to disclose my (or my dependents’) health care information to my insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits and payments for related services. This consent will remain active unless I cancel it in writing.