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    Please do not complete this form if you have not made an appointment with us already to be tested

  • Registration Form

  • Patient Information

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  • Insurance Information

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  • In Case of Emergency

  • ASSIGNMENT AND RELEASE:

    ·         I hereby assign my insurance benefits to be paid directly to the physician

    ·         I understand that I am financially responsible for all non-covered services, copays, deductibles and/or coinsurance. I authorize and give consent for my provider to bill me directly for recommended services performed that are not covered or not exempted under the terms of my health plan.

    ·         I authorize the physician to release any medical information required to process this claim.

  • CONSENT TO TREAT

    ·         I authorize my provider’s office to conduct telehealth visits when necessary.

    ·         I authorize New Path Medical Center to identify and carry out the appropriate treatment and/or procedure for any identified condition(s).

    ·         I understand I have the right to refuse any procedure or treatment

    ·         I understand I have the right to discuss all medical treatments with my clinician.

    ·         I authorize New Path Medical Center to perform any laboratory testing deemed clinically necessary.

  • The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize New Path Medical Center or insurance company to release any information required to process my claims.

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  • Patient History

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