Patient Registration Form

Please correct the errors described below.

PATIENT INFORMATION

AUTHORIZATION OF COMMUNICATION: I authorize Dr. Myles & Associates, LLC to communicate reminders, insurance items, lab results and or imaging results the following ways. Please choose primary and secondary preferences (Phone, Email, Text(data rate may apply))

IN CARE OF EMERGENCY CONTACT:

AUTHORIZATION TO RELEASE MEDICAL/FINANCIAL:

I authorize Dr. Myles & Associates, LLC, LLC, its representatives, physicians and staff, to release/share any and all medical and financial information to the following individual(s). The individuals listed below have authorization to talk with Dr. Myles & Associates, LLC on the phone or in the office. I understand that authorization to anyone other than myself is voluntary and I can revoke authorization and any time.

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INSURANCE ASSIGNMENT AND RELEASE:

I hereby authorize my insurance benefits to be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the physician to release any information required in the processing of this claim and all future claims.

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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