Patient Registration Form

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Insurance Information

PRIMARY INSURANCE

SECONDARY INSURANCE

TERTIARY INSURANCE

Release of Medical Information

Authorization for Treatment, Release of Information, Assignment of Benefits and Acknowledgement of Responsibility for Payment of Services:

I hereby give my consent to Dr. Garry Peers, Dr. Tim Roytman, Dr. Jason T. Smotherman to provide the necessary treatment. I authorize the release of medical information to my insurer and its agents, physicians, hospitals and other medical providers to determine payable benefits for services rendered. I request payment of authorized Medicare and other insurance benefits be made on my behalf to the above physicians for any services that were provided. This assignment will remain in effect until revoked in writing. I understand that I am financially responsible for all charges incurred and, in the event, that insurance payment is sent directly to me, I will remit payment to this office. If my insurance does not pay any bill submitted, I acknowledge these bills are my responsibility and will guarantee payment. I further agree to any reasonable cost, including attorney and collection agency cost, in the event my account becomes delinquent.

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.

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