General Consent Form

Please correct the errors described below.

We appreciate the opportunity to serve you and desire to provide you with the best service possible. The information below is intended to ensure you are aware of certain treatment, financial, and privacy policies. If you have any questions, please inform a member of our front desk staff. Thank you.

Consent For Treatment

I desire to be seen and treated by Malika Tuli, M.D., (and/or her associates) and hereby give my consent for the clinic, its physicians, and employees to see and treat me, as they deem necessary and appropriate for diagnosis and treatment. I authorize and consent for examinations, blood tests, laboratory procedures, injection of medications, local anesthesia, surgery, and other services, treatments, or procedures rendered or performed at the clinic or ordered by its physician or employees. I further understand that state law requires this practice to report any communicable diseases to the health department.

Receipt of Notice of Privacy Practices

I acknowledge that a copy of my physicians Notice of Uses and Disclosures of Protected Medical Information (Notice of Privacy Practices) has been made available to me.

Consent for Financial Responsibility

It is the policy of this office that the adult presenting the child for treatment is responsible for payment of the patient portion at the time of service (e.g., deductibles, copayments, and non-covered services.) I understand a parent must accompany children under the age of 18 to every appointment.

I request authorized benefits be made on my behalf to Malika Tuli, M.D. for any services furnished to me. I authorize any holder of medical information to release to the insurance carrier any information needed to determine these benefits payable for related services.

It is my responsibility to contact my insurance company and/or employer to verify that Dr. Malika Tuli is a participant in my insurance plan. If my insurance plan requires a referral, it is my responsibility to obtain the referral prior to being treated. If a referral is required and I fail to obtain one, I will be financially responsible for any services rendered.

If it becomes necessary, I also understand that I am responsible for reasonable collection costs and/or attorney fees incurred for collection of this account. I agree that in order to service my account or to collect any amounts owed to the practice, I may be contacted by telephone at any phone number associated with my account. I may also be contacted by text messages or emails, using any email address provided. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

Our practice accepts cash, check, bank debit card, MasterCard, Visa, American Express, or Discover. Each instance of a returned check is subject to a $20 processing fee.

I understand that if I fail to reschedule or cancel an appointment 24 hours prior to the appointment then a $50 no-show fee will be applied to my account. I understand that the no-show fee must be paid prior to rescheduling my appointment and that it is not reimbursable by my insurance company or able to be paid with my health savings card.

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