Financial Policy

I authorize payment for services be made directly to The Family Doctors which may be otherwise payable to me from all sources including but not limited to my medical insurance, my employers workers compensation carrier or other parties for  surgical/medical benefits with whom I have contracted. Such benefits will not exceed The Family Doctors billed charges for these services. I understand that I am financially responsible to e Family Doctors for charges not covered by this assignment and will adhere to the financial policies of The Family Doctors in the collection of these charges. I accept full responsibility for providing The Family Doctors accurate and complete information needed for their assisting me in processing my claims for reimbursement of medical services. I authorize the refund of overpaid insurance benefits where my coverage is subject to coordination of benefits. I understand that if anything is deemed "not medically necessary" or "investigational" by my insurance company that I am responsible for payment of these services. I have the right to ask for current pricing at anytime in advance of a procedure or services being rendered.

I hereby authorize and direct The Family Doctors physicians together with associates and assistants of their choice to administer or perform medical treatment on the patient identified, including any additional procedures/services as they deem necessary or reasonable, including but not limited to the administration of injections, x-ray or other radiological and laboratory services. I also hereby authorize the release of medical records to referring physicians and to my insurance companies for the purpose of payment, treatment and healthcare operations. This authorization for consent to medical treatment or surgical procedures is and shall remain valid until revoked.

I hereby acknowledge the offer and/or receipt of the Family Doctors Notice of Privacy Practices and been provided an opportunity to review them. I have read, understand and agree to all of the above listed policies and practices.

Create your own automated PDFs with JotForm PDF Editor