I, the undersigned, as the patient (or authorized person), consent to any treatment and/or procedures rendered to me that may, under the judgment and instruction of the treating provider, be considered advisable or necessary. I understand that if any extensive procedure or surgery is to be performed, it will be fully explained to me, including the risks and alternatives, and my specific consent will be necessary.
I understand that any ancillary services (x-rays, lab tests, etc. that may be ordered by the medical provider while I am in clinic are not included in my clinic bill and that I will be billed separately for these services.
In addition, I authorized Idaho Physicians Clinic, Bingham Memorial Hospital, along with any contracted provider services, to furnish all medical and financial information for this visit to Medicare, Medicaid, my insurance carrier and/or any agency working on their behalf. I hereby authorize payment of benefits on my behalf to any of the providers performing services related to this encounter. I understand that certain services may not be covered or may be denied by my insurance carrier and I hereby guarantee payment of the charges incurred and agree to pay any unpaid balance. I authorize the use of my medical records for performance improvement activities at this facility.
I, the undersigned, have read the above authorizations and understand the same and certify that no guarantee or assurances have been made as to the results or outcome of treatment or diagnosis.
I understand that I may be charged an amount of $35 if I had an established appointment and have failed to cancel or postpone the event 24 hours in advance