I hereby authorize Drs. Nash and Borden and Epic Care to release any information acquired in the course of my treatment to my insurance company, employer, or third party payer as required for claims filed, quality assurance, health plan administration, or compliants/grievances. I understand that the specific information to be released may include but is not limited to history, diagnosis and/or treatment of all related illnesses including HIV virus and Acquired Immune Deficiency Syndrome (AIDS).
I authorize direct payment to be made to Epic Care for any and all medical or surgical services rendered. In understand that if any services or charges are not covered or if Epic Care is unable to verify eligibility, that I am responsible for all charges incurred for services rendered.
I hereby voluntarily consent to such healthcare encompassing diagnositc procedures and treatment by Drs. Nash and Borden and Epic Care as may be necessary in their judgement. I have relied on my physician for information in this regard and acknowledge that no warranty or guarantee has been made to me as a result or cure. This form ahs been fully explained to me and I certify that I understand it's content.