I, or my parent or guardian, have completed this form and consent that it is correct to the best of my knowledge. I authorize you to render necessary evaluation and treatment to myself/child/ward. I consent to Health Services and the HIPAA Privacy Notice. The practice will bill my insurance company for its services. I consent to all communication, including but not limited to communication about my medical condition and advice from my health care providers by the following means; Voice, text and email. If a check is sent directly to you from the insurance company for this testing, you agree to sign it and send the check directly to The MediStation LLC.