Patient Financial Information Sheet "*" indicates required fields Assignment of Benefits I understand that payment in full is due at time of service unless other arrangements have been made.First Name*Middle NameLast Name*Preferred NameDate of Birth* MM slash DD slash YYYY Home PhoneCell PhoneMarital Status*SingleMarriedDivorcedPrimary Insurance CompanyName of Policy Holder*Policy Holder Date of Birth* MM slash DD slash YYYY Employer*Relationship to Policy Holder* Self Spouse Child Guardian Power of Attorney FileMax. file size: 256 MB.Date of Birth* MM slash DD slash YYYY First Name*Last Name*Responsible PartySecondary Insurance CompanyPolicy Holder Date of Birth MM slash DD slash YYYY Name of Policy HolderEmployerRelationship to Policy Holder Self Spouse Child Guardian Power of Attorney Responsible PartyDate of Birth* MM slash DD slash YYYY First Name*Last Name*Authorization and ReleaseI authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to the doctor insurance benefits otherwise payable to me. I understand that my insurance carrier may not cover all or may pay less than the actual bill for services that I received. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I authorize the release of medical information including the diagnosis, treatments and financial information rendered to me and/or my child to the following individuals… List name(s)*Signature of Patient / Parent if a minor*This authorization expires 10 years from signature date.Date* MM slash DD slash YYYY HIPAA Privacy Practice AcknowledgmentNOTICE OF PRIVACY PRACTICESSignature*I have received or was offered and declined a notice of privacy practices.Date* MM slash DD slash YYYY Upload a photo of your insurance cardMax. file size: 256 MB.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
