Custom Built
HIPAA Forms

Please inform our office if you have additional insurance coverage that may be utilized as well.

• Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for any expenses incurred in collecting your account.
• I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.
• I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes in my medical status.
• I acknowledge the conditions of the HIPAA Agreement for the purpose of my medical information being released to third party entities as part of treatment with the provider.