Patient Information

If Patient is minor:

FINANCIAL AGREEMENT AND AUTH0RIZATION FOR TREATMENT

I authorize treatment of the person named above and agree to pay all fees and charges for such treatment. I agree to pay all charges for me and members of my family shown in statements. Promptly upon presentment thereof, unless credit arrangements are agreed upon in writing. Charges shown by statements are agreed to correct and reasonable unless protested in writing within thirty days of billing date. In the event legal action should become necessary to collect unpaid balance due for medical services rendered to me and my family, I/we agree to pay reasonable attorney fees or other such costs as the court determines proper. It is agreed that payments will not be delayed or withheld because of any insurance coverage or the pungency of claims thereon and all proceeds of insurance are assigned to this office where applicable but without their assuming responsibility for the collection thereof. A copy of this assignment is as valid as the original, NOTICE: do not sign this agreement before you read and agree to it. You are entitled to a copy of this agreement at the time you sign. Keep it to protect your legal rights .

AGREEMENTS: The above information is for the purpose of obtaining credit and is warranted to be true. I authorize the creditor or his agent to make credit investigations including employment verification.

I hereby acknowledge that I received a copy of this medical Notice of Privacy Practices. I further acknowledge that copy of current notice will be posted in the reception area, and will be offered a copy of any amended Notice of Privacy Practices at each appointment.

Extended Authorization Option:

Please list any persons you would like to authorized to have access to your billing, appointment or health information (with exclusion of information that is protected under state of federal law) such your spouse, caretaker or other family member.