BAR Patient Financial Agreement

Patient Name:

Today's Date:

Other family members that are patients:

Referred by:

Primary Care Physician:

Phone:

EMERGENCY CONTACT INFORMATION:

In case of Emergency, who should be notified?

Phone:

Relationship to patient:

Do you give our office permission to discuss your medical information with family members?

YES NO

If yes, please provide their names and phone numbers below.

Name:

Relationship:

Phone # (day):

Phone # (evening):

May we leave personal medical information on your answering machine or cell phone?

YES NO

May we e-mail personal medical information to you?

YES NO

E-mail address:

RECEIPT OF NOTICE OF PRIVACY PRACTICES:

My signature below indicates that I have received and/or reviewed a copy of my physician's Notice of Uses and Disclosures of Protected Medical Information (Notice of Privacy Practices). I have been given the option of signing a separate Patient Consent Form.

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.

Patient or Responsible Party Signature:

Date:

PAYMENT POLICY:

I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to the physician. Payment is required for all services at the time they are rendered. We accept payment in the form of cash, check or credit card. You may be asked to pay any unmet deductible, non-covered services and copayments. In the event your account must be turned over to collections, a $10 collection fee will be added to your account. Your signature below signifies your understanding and willingness to comply with this policy.

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.

Patient or Responsible Party Signature:

Date:

Your information will be encrypted.