Patient Information Form

To be Completed by Patient at Time of Appointment

Please correct the errors described below.

Please Choose One:

Responsible Party (If Patient is a Minor)

Policy Holder (If Different from Patient)

Emergency Contact Information

Insured Information (If Insured Only)

Assignment of Insurance Benefits: In the event that the undersigned is entitled to benefits of any type as part of any insurance policy covering patient or any other party liable to patient said benefits are hereby assigned to ENTA for application to patient's bill. The undersigned shall be responsible for any and all charges not covered by such an insurance policy or policies.

Financial Agreement: The undersigned agrees, whether signing as a patient or an agent, that in consideration of the services to be rendered to the patient he / she hereby individually obligates himself / herself to pay any balance outstanding after reassignment and payment of insurance benefits. Should the account be referred to an outside agency for collection, the undersigned shall pay reasonable collection and / or attorney expenses. In the event of cash payment for services or if patient is to self-pay, payment in full is due at the time services are rendered.

Release Information: ENTA may disclose all or any part of patient's record to any individual or corporation which is or may be liable under a contract with ENTA, to the patient or to a family member or employer of the patient for all or part of ENTA's charges, including but not limited to: hospital or medical service companies, insurance companies, worker's compensation carriers, welfare or public assistance funds, private foundations or charitable organizations, or the patient's or guarantor's employer/s. ENTA shall comply with Federal Privacy Act and HIPAA and shall not disclose patient information to parties not authorized to receive such information under these regulations.

I attest that the information I have provided to ENTA is true and accurate and I agree to the terms outlined above.

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

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