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PATIENT

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PATIENT

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GUARANTOR

EMERGENCY CONTACT

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ASSIGNMENT OF BENEFITS, FINANCIAL DISCLAIMER, AND RELEASE OF RECORDS: Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some insurance companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-payment, or any balance not paid by your insurance within 60 days of the date we submit your claim.
IN ORDER TO CONTROL YOUR COST OF BILLING, WE REQUEST THAT OUR CHARGES FOR OFFICE VISITS BE PAID AT THE CONCLUSION OF EACH VISIT.
If this account is assigned for collection and/or suit, collection costs and/or interest, and/ or attorney fees, and/or court costs will be added to the total amount due. To the extent necessary to determine liability for payment and to obtain reimbursement, I authorize disclosure of portions of the patient's records. I hereby assign all benefits, to which I am entitled, to the provider of services. This assignment will remain in effect until revoked by the provider in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges, whether or not they are paid by insurance. I hereby authorize said assignee to release all information necessary to secure payment. I hereby authorize said assignee to release all information necessary to secure payment.
Charges to the above named patient will be my responsibility as if I received treatment.

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

I hereby acknowledge that I rec:eived a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that a copy of any amended Notice of Privacy Practices will be available at each appointment.

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Por la presente reconozco que he recibido una copia del Aviso de esta práctica medica de privacidad . Además, reconoce que una copia del aviso actual será de recepción, y que una copia de cualquier aviso modificado de privacidad prácticas estará disponible en cada cita.

DIRECCION

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