Complete Only if Using Insurance
Deductible Met? *
Secondary Insurance *
Job Related Injury-Workmens Comp. Co *
Office Billing and Insurance Policy
                               1. I authorize use of this form on all of my insurance submissions.
                               2. I authorize the release of information to my insurance company(s).
                               3. I understand that I am responsible for the full amount of my bill for services provided.
                               4. I authorize direct payment to my service provider.
                               5. I hereby permit a copy of this to be used in place of an original.
Signature *
It is your responsibility to pay any deductible amount, co-pay, co-insurance amount or any other balance not paid by your insurance the day and time serviced provided.
There will be a $25.00 service charge on all returned checks.
In event that your account goes to collections, there will be a $20 collection fee added to your balance.
There is a 24-hour cancellation policy which requires that you cancel your appointment 24 hours in advance to avoid being charged.
Signature *
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