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Medical Information




Please Read and Sign

I hereby authorize the release of any information necessary to complete and process my insurance claims during the period of surgical care.

Payment of the office visit charge is expected on your first visit. I understand and agree that health and accident insurance policies are an agreement between the insurance carrier and myself. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. Although I have requested the doctor to bill my insurance company on my behalf, I clearly understand that it is still my responsibility to make sure the bill is paid in a reasonable time. If for any reason any portion of my bill is not paid by my insurance, I further agree to make arrangements for prompt payment of the bill. I also understand and readily agree that if I suspend or terminate my care and treatment, and fees for professional services rendered to me will be immediately due and payable.

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