AUTHORIZATION FOR RELEASE OF INFORMATION
I authorize the use of disclosure of my individually identifiable health insurance information necessary to process insurance claims. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.
AUTHORIZATION FOR ASSIGNMENT OF BENEFITS FOR INSURANCE
I authorize payment of medical benefits to my provider for services performed.
Appointment cancelled with less than 24 hour notice will be charged to me at the full fee per hour. I am responsible for the entire balance of services performed regardless of whether there is insurance coverage. Secondary insurance will be billed as a courtesy.
I understand and agree to the above stated financial policy.