Patient Financial Information Sheet

I understand that payment is due in full at time of service unless other arrangements have been made.
Name of Patient*
First Last
DOB*
MM slash DD slash YYYY
Name of Insured
First Last
Relation
DOB
MM slash DD slash YYYY
Address of Insured (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Insurance Carrier
ID#
Policy#
I 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 pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
I authorize the release of any information including the diagnosis and the records of any treatment or examinations rendered to me or my child to:
Signature of patient or parent if minor
Date
MM slash DD slash YYYY
HIPAA Privacy Practice Acknowledgement*
- I have read and agree to the Privacy Policy
Signature
Date
MM slash DD slash YYYY

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