By providing my electronic signature below, I hereby authorize and give consent to The Purcell Clinic providers and other practice professionals providing outpatient medical treatment, supplies, drawing blood, or any other procedure related to my healthcare or to my child/dependent as determined necessary in their professional judgement.
I understand that I am financially responsibile for all charges paid or unpaid by my insurance company. I hereby authorize the release of information necessary to file a claim with my insurance company and assign payment of all medical benefits to The Purcell Clinic. I also authorize the release of my childs/dependents medical information by or between any of my treating physicians and my insurer or any other entity included in the administration of my child's/dependent's health benefits.
All information provided is truthful and accurate to my knowledge. This consent is in place until termination in writing by the undersigned.