Financial Agreement

Please Fill Out The Form

Financial Agreement

FINANCIAL AGREEMENT

In consideration of the patient receiving services from the Physician, I agree:
• I am responsible for all expenses for treating the patient.

• Payment of charges is due at the time of the appointment.

• If the Physician files my insurance for me, I agree to pay for non-covered insurance
benefits, co-insurance, co-pays, and deductibles.

AUTHORIZATION TO RELEASE INFORMATION & TO PAY BENEFITS

I authorize the Physician to release any of my medical information, including drug and alcohol and
HIV positive test results, to my insurance company(s), as needed to process my insurance claim.

I authorize my insurance company to make payments directly to the Physician for covered medical
and/or surgical services.