Please check each item in the box indicated "Yes" or "No" as they relate to your recent health.

I. RELEASE OF INFORMATION - I, the below named patient, do hereby authorize any physician examining and/or treating me to release to any third payer (such as an insurance company or government agency. Example: Blue Shield of Florida or Medicare) any medical, psychiatric condition, alcohol, and/or drug related condition and records concerning diagnosis and treatment when requested by such third party for its use in connection with determining a claim for such treatment and/or diagnosis.

II. PHYSICIAN INSURANCE ASSIGNMENT -I, the below named subscriber, do hereby authorize payment to any physician examining and/or treating me of any group and/or individual surgical and/or medical benefits herein specified and otherwise payable to me for their services.

III. MEDICARE/MEDICAID -- Patient's certification authorization to release information and payment request. I certify that the information given by me in applying for payment under Title XVIII/XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to Social Security Administration Division of Family Services, or its intermediaries or carriers any information needed for this of a related Medicare/Medicaid Claim. I hereby certify that all Insurance pertaining to treatment shall be assigned to the physician treating me.

IV. GUARANTEE OF PAYMENT - I, the below named patient/guarantor, do hereby guarantee payment of all charges incurred for the account of the patient named below. I further agree to waive demand and notice of non-payment and protest and in case suit shall be brought for the collection hereof or the same is collected upon demand of any attorney, I agree to pay all cost of collection, including reasonable attorney fees.

V. I PERMIT A COPY OF THESE AUTHORIZATIONS AND ASSIGNMENTS TO BE USED IN PLACE OF THE ORIGINAL, WHICH IS ON FILE. This assignment will remain in effect until revoked by me in writing.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. I understand that it is my responsibility to pay any deductible amount, coinsurance, or any other balance not paid for by my insurance or third payer within a reasonable period of time not to exceed 60 days.

7300 Sandlake Commons Blvd.
Complex A, Ste. # 112
Orlando, FL 32819

In an attempt to preserve the confidential nature of the doctor-patient relationship, it is required that you complete the information listed below regarding appointments and other administrative matters.

agree to pay $50.00 for any appointment that has been cancelled, less than 24 hours, prior to scheduled time.

I understand that no exceptions will be made, and the policy is strictly enforced.