INSURANCE AUTHORIZATION AND ASSIGNMENT

I directly assign all medical benefits to Grapevine Women’s Health & Gynecology and understand that I am financially responsible for all charges. I authorize Grapevine Women’s Health & Gynecology to release necessary information to secure payments of benefits. I further agree that a copy of this agreement shall be as valid as the original. I also authorize Grapevine Women’s Health & Gynecology to provide my medical care, or the medical care of my dependent.

PATIENT ACKNOWLEDGMENT AND CONSENT: DIAGNOSTIC SUTDIES

I voluntarily consent for myself of my minor child or other patient named below, to all medical treatment and health care related services that my provider at Grapevine Women’s Health considers medically necessary for me, or the patient named below. These services may include diagnostic, imaging, and laboratory services.

Tests may be performed as part of a routine checkup or to make, rule out or confirm diagnosis. At Grapevine Women’s Health (GWH) we make every effort to select the preferred laboratory within your insurance network. Any costs associated with the recommended studies are separate from Grapevine Women’s Health. I understand I am responsible for any charges associated with the labs or diagnostic studies my insurer may not cover.

By signing below, I am indicating that I have reviewed, acknowledge, and consent to the terms described above.