Patient Information Form

Signature

Please remember that insurance is considered a method of reimbursing the patient for fees subsittue paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to a the deductible amount, co-insurance, or any other balance not paid by your insurance.In order to control the cost of bilings, we rwequest that charges for office visits be paid at the conclusion of each visit. If this acount is assigned to an attorney for collection and / or suit, the practice shall be entitled to reasonable attorney's fees and cost of collection. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered to be as valid as the original. I understand that I am fiinancially responsible to pay for all charges. wheter or not paid by insurance.
Authorization to pay benefits to physizians I hereby authorize payment directly to the physician of any benefits, otherwise payable to me for his services realizing I am responsible for noncovered services. Authorization to release information I hereby authorize my physicians to release any information aquired in the course of my treatment to process insurance claims.
I agree to the assignments and financial responsibilities as indicated on this form.

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