Authorization to pay benefits to physician:
I authorize my insurance carrier to assign all medical and/or surgical benefits, if applicable Clinic P.L.L.C…. I also authorized release of medical information necessary to process insurance claims. (Via electronic mail / ground mail / fax)


Authorization to release information:
I hereby authorize The undersigned Physician to release any information acquired in the course of my examination or treatment to the Health Care financing Administration and its agents and two specific insurance carriers, third party payers or others involved in processing and collections of claims needed to determine these benefits for related service.


Financial responsibility:
The undersigned guarantees payment to South Heart Clinic P.L.L.C. for services rendered in the event insurance does not cover all fees until account is paid in full and I agree to waive All rights of exemption under the state of Texas.


General consent for treatment:
By signing below, I (or my authorized representative on my behalf) authorize South Heart Clinic P.L.L.C. (Physician and/or Physician Assistant) and staff to conduct any diagnostic examination/s, test/s and procedures and to provide any medications, treatment necessary to effectively assess and maintain my health, and to assess, diagnose and treat my illness. I understand that it is the responsibility of my individual treating Health Care Providers to explain to me the reasons for any particular diagnostic examination, test or procedure, the available treatment options and the common risk and anticipated organs and benefits associated with these options as well as alternative courses of treatment.


Referral policy:
I understand it is my responsibility to obtain a referral through my primary care physician office if required by my insurance company. Failure to do so will result in charges being billed directly to myself.


Payment policy:
Copayment is to be collected at time of service. All Medical Services provided are directly charge to the patient or responsible party. However, you will be responsible for any balance deemed patient responsibility / non-payable / non-covered by your insurance is billed accordingly. Payment is expected in full upon receipt of statement or payment arrangements must be made with our billing office.
NO future services may be added to this payment arrangement all future Services must be paid in full.

 


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INFORMATION:


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Physical Address:


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Mailing Address (Leave blank if same as above):


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EMPLOYMENT:

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PRIMARY SUBSCRIBER:

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SECONDARY SUBSCRIBER:

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EMERGENCY CONTACT:

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DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. I certify that the information given by me as documented above is correct. I also certify that I have a signed and been given the following for review and that copies of these forms have been made available to me upon request.

Notice of Privacy Practices / Financial Policy
Type your full name in the signature place provided: