CONSENT
Consent to release:
I hereby authorize physicians of this practice to release any and all medical information to the above name insurance carrier (or to a designated attorney) for purposes of claims administration and evaluation, utilization review and financial audit. This authorization remains valid and effective from the date of signing until it is revoked in writing. I have read this authorization and understand it.
Consent to assignment:
I hereby assign payment of medical services to this practice to which I am entitled or have incurred for medical and/or surgical expense relative to services rendered here. I understand I am financially responsible to said group for charges not covered by this assignment. I further agree in the event of non-payment to bear the cost of collection, and/or Court cost and reasonable legal fees shoud this be required.
Consent to treat:
I authorize this practice to provide medical care to my child and authorize treatment of care in my absence if my child is accompanied by the following care giver (select all that apply.