I authorize Ace Health and Wellness Center to perform, evaluate and treat, as they deem necessary. I further authorize my insurance company to pay Ace Health and Wellness Center all medical benefits. I understand that ultimately, I am responsible for all charges not covered by my insurance as well as all deductibles, coinsurance, and copay amounts as determined by my insurance company. I understand that I will be responsible for all collection and legal fees if my account is placed with an outside collection agency. I hereby authorize Ace Health and Wellness Center to release records pertaining to my treatment to my insurance company or other third parties responsible for payment of my medical charges, including review activities related to my physician's participation with my health plan. I authorize the use of this signature on all my insurance submissions, whether manual or electronic. I certify that the information above is true and correct to the best of my knowledge and will notify Ace Health and Wellness Center of any changes to this information.

I also acknowledge and understand the practice's appointment policy. Established patients who fail to provide at least 24 hours' notice to cancel or reschedule an appointment may be charged a no show fee of $25. Repeated no-shows or late cancellations may result in increased fees and, after multiple occurrences, dismissal from the practice. New patients who fail to attend their initial appointment may not be rescheduled. No-show fees are the patient's responsibility, are not billable to insurance, and are due at the next office visit.

By signing below, I acknowledge that the information I provided is correct to the best of my ability