I acknowledge that the above services, the potential risks and benefits of the services as well as the risks associated of not participating in the above services have been explained to me and all questions have been answered. No guarantee or assurance has been given by anyone as to the results that may be obtained from these services.
My signature on this form acknowledges that a copy of the Bates County Health Center Notice of Privacy Practices has been made available to me. I understand that this document provides an explanation of the ways in which my health information may be used or disclosed by Bates County Health Center and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
With this signature I acknowledge the receipt of medical services and authorize the release of any medical information necessary to process this claim for health care payment only. I authorize payment to the provider and understand that my claim will be submitted to insurance and that I will be responsible for any deductible, co-payments, coinsurance, or client fees at the time of services. I understand that I will receive a statement if my account has a balance due and that the Bates County Health Center is not responsible for collection of my insurance claim or for negotiating a settlement on a disputed claim that I am responsible for payment of my account.