Consent and Permissions
To the best of my knowledge, all of this information is true and correct. I understand that I am
responsible to pay for all services rendered to me and that I am willing to make specific arrangements
to pay what is not covered by insurance on a timely basis. (PLEASE REMEMBER THAT
INSURANCE IS CONSIDERED A METHOD OF REIMBURSING THE PATIENT FOR FEES PAID
TO THE DOCTOR AND IS NOT A SUBSTITUTE FOR PAYMENT.)
I grant permission to my physician to mutually exchange medical information with my referring
physician(s) and/or their associates. To the extent necessary to determine liability for payment and to
obtain reimbursement, I authorize disclosure of portions of the patient’s medical record to my insurance
and Medi-gap carriers. If this account is assigned to an attorney for collections and/or suit, the
prevailing party shall be entitled to reasonable attorney’s fees and cost of collection. I hereby assign all
medical benefits to which I am entitled to my physician for services rendered to me or my dependent.
This assignment will remain In effect until revoked by me in writing. A photocopy of this assignment is
to be considered as valid as the original.