for the services furnished to me by the physician. I authorize any holder of medical information to release to the Health Care Financing Administration and its agents any information needed to determine these Benefits or the Benefits payable for related services.
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 appointment time is especially reserved for you.
Please be advised that this office requires a 24-hour notification for ALL cancelled appointments.
A $50 charge will be collected for the missed appointment session.
You are responsible for the time you schedule with this office.
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.
acknowledge that I have been provided with a copy of the health Information Privacy Rights [HIPAA]
, have also been advised that the Notice is posted on the U.S. Department of Health and Human Services website at www.hhs.gov/ocr/hipaa or by calling 1-866-627-7748.
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.
to conduct any tests, examinations and treatments, which in his/her judgment are necessary for the care and treatment of myself or my dependent.
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.
to conduct any tests, examinations and treatments, which in his/her judgment are necessary for the care and treatment of myself or my dependent.
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.
Over the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully and check off your response
Please answer question as best as you can by putting a check in the appropriate box.
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