1 Start 2 Patient Insurance Information 3 Secondary Insurance Carrier 4 Release 5 Complete

By Signing Below, I acknowledge that:


The doctor, associate doctor and staff of the medical practice notes on this form and hereafter referred to as DOCTOR, are authorized to treat the patient named on this form. DOCTOR is authorized to collect, use and exchange individually identified health information consisting of the patient's past, present and future medical information and personal information to treat patient, communicate with patients' other health care providers, seek payment, carry out necessary business functions and mandated government reporting requirements. These situations and others, as well as your rights regarding this information are explained in our separate notice of privacy practices provided to you.

I have received a copy and acknowledge both HIPPA and financial compliance policies for this office.