I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION TO OTHER PHYSICIANS PARTICIPATING IN MY CARE

I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION TO THE INSURANCE COMPANY LISTED ABOVE FOR THE PURPOSE OF PROCESSING MY INSURANCE CLAIMS

I AUTHORIZE THAT ANY BENEFITS DUE BE MADE PAYABLE TO DIN NEUROLOGY AND DALLAS ADHD AND HEADACHE SPECIALIST (NEURO CARE LLC)

I AUTHORIZE THE VIRTUAL MEDICAL SCRIBE ALONGSIDE DR. DIN IN THE ROOM DURING MY APPOINTMENT.

Patient Name {patientName}

Patient DOB {dateOf}

Signature *    

Date *     

AUTHORIZATIONS:
If you wish to request an authorization to release your records per Section III, Paragraph A of the Notice of Privacy Practices, please complete this section. This section is not required. Treatment, payment, enrollment, or eligibility for benefits (as applicable) will not be conditioned upon signing of this authorization section. You have the right to revoke this authorization at any time by writing to DIN NEUROLOGY AND DALLAS ADHD AND HEADACHE SPECIALIST (NEURO CARE LLC). Authorization can be revoked at any time except to the extent that action has already been taken based on this authorization. 
I hereby authorize the following individuals to view, discuss, or receive my information:

Name First Name     Last Name  

Phone Number   Area Code     Phone Number  

Relation to Patient      

The above authorization shall be in effect until the earlier of two (2) years after the death of the patient for whom this authorization is made OR the following specified date: Authorization expires on:
Date    

RESTRICTIONS:
If you wish to request a restriction on the release of your records per Section IV, Paragraph D of the Notice of Privacy Practices, please complete this section. This section is not required.
I hereby request the following restrictions on the use and/or disclosure of my information: 
   
   
SIGNATURES:
By signing below, you acknowledge that you have received read the Notice of Privacy Practices prior to any service being provided to you by the Practice, and you consent to the use and disclosure of your medical information.

Patient's Name    First Name *     Last Name *    

Patient DOB Date *    

Patient Signature    Signature *    

Date Date *
   

Thank you for choosing DIN NEUROOGY AND DALLAS ADHD AND HEADACHE SPECIALIST (NEURO CARE LLC). We are committed to building a successful relationship with you and your family. Your clear understanding of our financial and office policies is an important part of that relationship. Below are the key points. For the full version of financial and office policies, please click here

1) We are committed to understanding your benefits and providing you with a cost estimate for your care before your appointment
2) Before your appointment, please inform us of any changes to your information such as name, address, phone numbers and/or insurance information.
3) We will collect for today’s care and any outstanding balance when you check in.
4) If you miss your appointment or if you cancel or reschedule an appointment within 1 business day, we may charge a late cancellation fee of $50.
5) Please let us know if you are running late to your appointment.
6) Paperwork such as FMLA, and Disability will be charged $50, to be paid in advance
7) By default, you will receive text messages and/or call for appointment reminders and information about your health care treatment
By signing below, you acknowledge that you were given the option to review the full Financial and Office policies document before signing, and you agree to the policies detailed in the full policy.

Patient Name    First Name *     Last Name *    

Patient DOB    Date *    

Patient Signature Signature *

Date    Date *    

   

I understand and agree that if I don’t have insurance coverage, I am expected to pay charges in full at the time, services are rendered.

Patient's Name    First Name *     Last Name *   

Patient DOB    Date *   

Patient Signature Signature *    

Date Date *