Demographics
Authorization and Release
Authorization for Treatment: I voluntarily consent to the administration and cost of care for myself and my dependents.
Assignment of Insurance Benefits: I authorize payment directly to this center for all benefits.
Guarantee of Payment: I understand that I am financially responsible and agree to pay all charges that are not paid or billed to insurance or any other third-party payer. I understand that I must pay in full today for all services rendered unless my insurance is accepted. I also understand that if my insurance is accepted, I must pay all applicable insurance copays, coinsurances, and deductibles today. If you are unable to verify my insurance at time of service, I will pay in full for all services.
Release of Records: I authorize this urgent care enter to lease (verbal or in writing) confidential medical information to any person or entity including my insurance carrier, employer if treatment is related to employment purposes, or other health care operations which may be liable to me or my practitioner(s) for charges for this treatment and for quality management, utilization review, transfer, and follow-up purposes.
Receipt of Privacy Practices: I acknowledge that I have received and read the Notice of Privacy Practices.
***NOTE*** Patient shall be responsible for the payment of medical service(s) if insurance does not make the full payment.
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