Secure Patient Information Form

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Patient Information

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Your email address will only be used to provide you information about events and classes we are hosting/sponsoring. We will not share this information.

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Marital Status

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Emergency Contact

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Insurance Information

Primary Insurance

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Secondary Insurance

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PATIENT PAYMENT AGREEMENT

I understand that I am responsible for my medical bill and accept responsibility for any charges not covered and paid by my insurance company or other third party resources.

  • By signing below, I authorize the release of my medical records to the insurance carrier as may be necessary to determine benefits and to process claims for health care services provided to the above named patient.
  • I authorize assignment of Medicare/Medicaid, other federal/state agents or any commercial insurance carriers to pay benefits directly to the provider of service(s).
  • This is a Lifetime insurance authorization granting the provider authority to file claims on my behalf.

In addition to the above patient payment agreement, I sign below acknowledging receipt of the office’s NOTICE OF PRIVACY PRACTICES

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Lets Get Started: Call for your private appointment | 907.276.2400