All the information on this form is true to the best of my knowledge.
Notice of Privacy Practice: I acknowledge that I was given the option to receive a copy of HIPAA and that I have read (or had the opportunity to read if I so chose) and understood the notice. Signature on file -Financial Information: I authorize the use of this form on all my insurance submissions. I authorize the release of information to all insurance carriers. I authorize my insurance benefits to be paid directly to the physician; if insurance benefits are paid to me I hereby agree to remit all payments directly to the providers. I understand that I am responsible for my bill if the insurance carrier does not pay because my coverage has been terminated or not active at time of service.
Please sign your name in the area below