Patient’s Right to Privacy: By signing below, I acknowledge that I have reviewed a copy of the Privacy Notice. Public copies of the Privacy Notice and Client’s Rights and Responsibilities brochure are posted in the reception area.
Consent for Treatment: By signing below, I consent to having my healthcare provider examine and treat me. I understand that this could include education, lab tests, and/or diagnostic procedures. I understand that my provider will explain the purpose of procedures and treatments and that I have the right to refuse the recommended treatment.
Income Verification: By signing below, I certify that all information regarding my income is
Authorization for Payment: By signing below, I give permission for my insurance carrier to pay Family Tree Clinic directly. I understand that I am responsible for payment of all co-insurance and deductibles, as well as any treatment, care and services not covered by my insurance.