I understand the importance of a truthful and complete Health History and realize that incomplete information may have an adverse effect on my treatment. To the best of my knowledge, the information I have given is complete and accurate.

Consent for Use and Disclosure of Health Information

Purpose of Consent: By signing this form, you will consent to our office use and disclosure of your protected health information to carry out treatment, payment, and healthcare operations.

Financial Agreement

1. Patients with insurance are required to pay full coinsurance of total bill at time of service.

2. All insurance quotes are estimates and are not a guarantee.

3. If treatment is rendered without insurance, payment is required in full.

4. Payment arrangements can be made prior to treatment.

5. If issued an insurance check for services rendered by Dr. Homrighausen, you are required to forfeit that check to Dr. Homrighausen

To Divorced Parents:

The parent who accompanies the child for care will be held responsible for all bills.

 

ALL ACCOUNTS ARE IN FULL UNLESS PRIOR ARRANGEMENT HAS BEEN MADE

Insurance Authorization

I have hereby given Dr Homrighausen consent to administer such anesthesia and medication and to perform such surgical procedures which are deemed necessary. I also consent to the release of information for insurance purposes and authorize the responsible third party to pay directly to Dr Homrighausen insurance benefits due me for services rendered. I also understand that I am responsible for any unpaid balance due to Dr Homrighausen.