You acknowledge that you have access to a copy of the Office Notice of Uses and Disclosures of Protected Medical Information (Notice of Privacy Practices). You further acknowledge that the Notice of Privacy Practices is available at the front desk upon request.
You authorize the release of medical information to your primary care or referring physician and consultants if needed and as necessary to process your insurance claims, insurance applications and prescriptions. You hereby assign your insurance benefits to be made directly to your physician for services rendered. Full payment is required for all services at the time they are rendered. Applicable co-payments and deductibles will be collected. You are responsible for knowing your benefits/coverage, and are responsible for any unmet deductible, non-covered services and co-payments. There is an annual administration fee of $250 per office visit, not to exceed $500 per calendar year. This is due at the time of visit, and is non-refundable. In the event that your account must be turned over to collections, a $20 collection fee will be added to your account. You attest that the above information is accurate and that you are an eligible member. You will be financially responsible for all charges that are not covered by your insurance company. Your signature below signifies your understanding and willingness to comply with this policy.
