If you would like to receive future correspondence regarding updates, promotions, news, etc please provide us with the following information and your preferred point of contact.
Your information will NEVER be given to a third party, nor will you be spammed. This information is for our office use only.
ADDITIONAL INSURANCE (IF APPLICABLE)
"I request that payment of authorized insurance benefits be made to Agilus Health, Inc. I authorize any medical information about myself needed to determine these benefits or the benefits payable for related services to be released to the insurance company and it's agents."
**We file your insurance as a courtesy to you. Your insurance coverage is ultimately a contract between you and your insurance company. If for some reason, whether it is pre-existing, failure to receive claim, etc they do not pay the claim, it is necessary that you understand that you are responsible for the balance and will pay for all services rendered to you by our clinicians through our office.
At Agilus Health, Inc, we are moving toward a very digital world. We take great importance in capturing as many moments throughout our clinic as possible. Most of these captured, digital moments are promoted online via Facebook, Instagram and other social media platforms, as well as on television. Unless we have additional consent from you individually, we will never show your face any any of our photographs/videos that are publicly displayed and/or promoted in some other way for marketing purposes. But this agreement is to inform you that you MIGHT be photographed or videotaped during your treatment, or any other activity within the clinic, but your face will NOT BE SHOWN unless otherwise agreed to.
You do have the right to completely decline even the “blurred” image of yourself to be publicly posted, so please provide the appropriate information below if it pertains to you.
"I hereby authorize Agilus Health, Inc to photograph/videotape me for the purpose of identification (patient chart), evaluation, progress documentation, educational marketing, and/or demonstration or treatment and/or progression or treatment or public and/or non public education."
Acknowledgement of Notice of Privacy Practices
Agilus Health, Inc. reserves the right to modify the privacy practices outlined in the notice.