Thank you for choosing our office. In order to serve you properly, we need the following information. All information will be confidential in accordance with HIPAA.
If you have any other coverage, please advise the front desk.
I authorize the release of any information concerning my (or my child’s) health care, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
I understand and agree that if my insurance is not in effect on the date of services rendered or if the insurance company determines that I am responsible for charges for which I have not previously rendered payment that I will pay in full for these services within 30 days of receiving a bill from James B. Maddox, M.D., P.A.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.