I certify that I. and/or my dependent(s). have insurance coverage with
all insurance benefits, if any. otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above·named doctor may use my health care information and may disclose such information to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year tram the date signed below.
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.
INCASE OF EMERGENCY, CONTACT
Date of Last:
Place a mark on ' Yes" or "No' to indicate if you have had any of the following: