Consent: I consent to the procedure for myself or as parent/guardian of named above, that may be performed during this visit including examination, emergency room referral, or services rendered to me as ordered by my physician or other health care professional. I voluntarily request and consent for independently contracted physicians to order all necessary tests and treatments. I understand that medical care is not an exact science and that no guarantee or warranty is being made as to my examination, treatment, result, or outcome. I understand that I am free to withdraw my consent and to discontinue participation in these tests at any time. ATX Covid Labs and Whole Family Chiropractors LLC is owned by Michelle Paris, DC. Results are for informational purposes only and does not propose a diagnosis. I understand that continuing on this form and booking an appointment indicates that the $35 processing/scheduling fee is not refundable. I understand that I can NOT use my insurance benefits if I have BCBS or Cigna health insurance UNLESS I have symptoms or known exposure and your medical team determines that testing is necessary.
Assignment of Benefits: I assign to Whole Family Chiropractors, LLC, ATX Covid Labs all right, title and interest in any and all health insurance and/or health plan proceeds/benefits from any plan(s) arising from the provision of any good and services provided by ATX Covid Labs (ACL) and/or physicians/health care providers thereof. This Assignment is made in accordance with 1204.054 Tex. Ins. Code. This includes 3rd party claims. A lien will be assigned if needed for 3rd party claims and is irrevocable unless both patient and provider submit so in writing.
Acknowledgment and Signature: The above information is true to the best of my knowledge. I have read, understand, and accept the consents, policies, and terms as set forth above. I authorize WFC and ATX Covid Labs to release any information required to process my claims and act on my behalf in Appeals. I understand that the $35 processing/scheduling fee is non-refundable.
By signing below you allow us to email you your results and/or leave a voice message.
By signing below you agree to the HIPAA Consent form located at: www.austincovidlabs.com/hipaa