AUTHORIZATION OF TREATMENT
Authorization and release for Docs Medical Inc. and its subsidiaries (Docs of CT, Docs Urgent Care, Zen Health and Wellness and Urgent Care Center), hereby referred as Docs Medical Inc. and Docs Urgent Care. I voluntarily consent to the administration and costs of medical and surgical procedures for myself or my dependent.

ASSIGNMENT OF INSURANCE BENEFITS/GUARANTEE OF PAYMENT
I authorize payment directly to Docs Medical Inc. and its subsidiaries (Docs of CT, Docs Urgent Care, Zen Health and Wellness, and Urgent Care Center) for all benefits payable to me. I understand that I am financially responsible and agree to pay all charges that are not paid or billed to my insurance or any third party payer. I understand that I must pay in full today for all services rendered unless my insurance is accepted. I also understand that if my insurance is accepted I must pay all applicable insurance co-payments, co-insurance, or deductible for services. I understand all services rendered are non-refundable under any circumstance. I understand that is I do not pay within 90 days upon receiving my billing statement; my account will be transferred over to “American Adjustment Bureau.”

RELEASE TO RECORDS
I authorize Docs Medical Inc. and its subsidiaries (Docs of CT, Docs Urgent Care, Zen Health and Wellness and Urgent Care Center) to release (verbal or written) confidential medical information to any person or entity Including my insurance carrier, employer (if treatment is related to employer purposes), or other health care operations which may be liable to me or my practitioner(s) for changes in treatment, for quality management, utilization review, transfer, and follow-up purposes.

I you selected 'Yes' for medications, please list the medication name, dose, frequency below. 

Authorization and release for Docs Medical Inc. and its subsidiaries (Docs of CT, Zen Health and Wellness, Docs Urgent Care and Urgent Care Center), hereby referred to as Docs Medical Inc.. This document is to be signed by the person legally responsible for the patient’s medical decisions relative to the treatment situation. I,

hereby acknowledge that Docs Medical Inc. has provided me with a copy of its notice of privacy policies that describe how medical information about me may be used and disclosed, and how I can access this information. I understand that if I have question or complaints I may contact Docs Medical Inc. Administration Directors at 203-874-3682 or by e-mailing contact@docsofct.com.

I also understand that I am entitled to receive updates upon request if and when for Docs Medical Inc. and its subsidiaries (Docs of CT, Zen Health and Wellness, Docs Urgent Care and Urgent Care Center), amends or changes its notice of privacy practices material in any way.

I allow Docs Medical Inc. and its subsidiaries (Docs of CT, Zen Health and Wellness, Docs Urgent Care and Urgent Care Center), to obtain prescription history from an external source:

Preferred contact number to call or text regarding appointment, labs or other tests/ consultations

I give permission to Docs Medical Inc. and its subsidiaries (Docs of CT, Zen Health and Wellness, Docs Urgent Care and Urgent Care Center) to provide notifications of my health information to:

I give permission to Docs Medical Inc. and its subsidiaries (Docs of CT, Zen Health and Wellness, Docs Urgent Care and Urgent Care Center)
to share health information via voicemail or text message.