New Patient Intake Form

Assignment of Benefits

I certify that I, and/or my dependent(s), have insurance coverage and assign directly to the treating physician all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Acknowledgement of Receipt of Notice of HIPAA Privacy Practice Guidelines

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our Notice before signing this consent. By signing this form, you consent to our use and disclosure of protected health information for treatment, payment and health care operations. The patient understands that: (1) Protected health information may be disclosed or used for treatment, payment or health care operations; (2) The Practice has a Notice of Privacy Practices and the patient has the opportunity to review this Notice; (3) The Practice reserves the right to change the Notice of Privacy Policies; (4) The patient has the right to restrict the uses of their information; (5) The patient may revoke this Consent in writing at any time.