Registration Form
I hereby assign my insurance benefits to be paid directly to the undersigned physician. I am financially responsible for any balance or non-covered service. I authorize the physician to release any information required to process my claim.
I have received the HIPAA Notice of Privacy Practices and have been given a copy if requested.
Disclaimer: 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.
Your information will be encrypted.