Please provide the Name, Phone Number and the Relationship to Patient
Secondary (if applicable)
- Consent for Treatment- I consent to necessary treatment, including drugs, predication, performance and operation of X-ray, or other studies that may be used by the physician, nurse, or staff.
- Consent for E-Prescribing- I have been made aware and understand that the medical practices and offices may use an electric prescription systemwhich allows prescriptions and related information to be electronically sent between my providers and my pharmacy. I have been informed and understand that my providers using the electronic prescribing system will be able to see information about medications I am already taking, including those prescribed by other providers. I give my consent to my providers to see this protected health information.
- Insurance- I understand this office participates in most insurance plans, including Medicare. I acknowledge that if I am not insured by a plan that thisoffice does business with, that payment in full is expected at each visit. I agree to provide to provide this office with my current insurance information.If I am insured with a plan that this office does business with, I will need to have a current card so that my coverage can be verified. There may be certain routine services performed during your visit(s), such as ultrasounds, X-rays, MRI, lab work, injections and/or other testing we feel is necessary for your treatment but may not be covered by your insurance contract. Knowing your insurance benefits is your responsibility. Please contact yourinsurance company with any questions you have regarding your coverage. By signing below, I agree that I will be responsible for costs not covered by insurance and for any costs not paid for by my insurance company, whether or not said costs are covered by my insurance contract.
- Co-payments and Deductibles- I acknowledge that all co-payments and deductibles must be paid at the time of service, as required by my contract with my insurance company.
- Cancellation/No-Show Policy- I understand and acknowledge that if I do not call to cancel an appointment, I may be preventing another patient fromgetting much needed treatment. Conversely, the situation may arise where another patient fails to cancel, and the office is unable to schedule me fora visit due to a seemingly “full” appointment book. If an appointment is not cancelled at least 24 hours in advance I agree to pay a $25 fee; this will notbe covered by your insurance company. If I am 15 minutes or more late for my scheduled appointment, I may be considered to have canceled my appointment without notice.
- Notice of Privacy Practices- I acknowledge that I received a copy of the notice of Privacy Practices.