1. I hereby authorize the physician and/or nurse at Srino Bharam, MD, PC office to administer such treatment and medication as may be deemed necessary or advisable in the treatment and diagnosis of my condition. This authorization is given voluntarily and I hereby acknowledge that no guarantees have been made to me as to the results of treatments and examinations at Srino Bharam, MD, PC's office.
2. I hereby authorize Srino Bharam, MD, PC to release any information acquired in the course of my examination or treatment to any person or corporation, including but not limited to the Social Security Administration, Insurance Carriers, Worker's' Compensation Carriers, Welfare Funds or Employers, PROVIDING such agent has a financial liability for my treatment at Srino Bharam, MD, PC.
3. I hereby give my permission, when applicable, for my Insurance Company to pay Srino Bharam, MD, PC's' office directly. I further agree to pay any balance due and payable.
4. I understand that I am responsible, prior to treatment, for inquiring with my Insurance Company as to the benefits of my policy for services provided by Srino Bharam, MD, PC.
6. I am visiting the doctor because: *