Patient Name:
    Preferred Name:
    Patient Account #:
    Address:
    City:
    State:
    Zip:
    Phone #:
    Cell #:
    Email Address:
    SSN #:
    Date of Birth:
    Age:
    Employer
    Occupation
    Work Phone #:
    Guarantor:
    Primary Insurance Coverage:
    Primary ID #:
    Secondary Insurance Coverage:
    Secondary ID #:
    Referring Physician:
    Referring Family/Friend:

    RELEASE OF INFORMATION, ASSIGNMENT OF BENEFITS, AND FINANCIAL RESPONSIBILITY

    I am requesting medical treatment by the physician at the Rosenberg Cooley Metcalf Clinic. I authorize the release of any medical information necessary for my insurance to process my claim. I understand that I am financially responsible for my bill, and I accept full responsibility for any charges from the physician or physician’s assistant remaining after payment of insurance benefits, and any legal/attorney fees or collections fees (up to 40%) that may be added as a result of nonpayment. I authorize direct payment to my physician at the Rosenberg Cooley Metcalf Clinic.

    The specifics of your financial responsibility are included in the Patient Financial Agreement.

    Patient Signature
    Signature:
    Date:

    As a courtesy to our patients we will file the claim with your insurance carrier with the understanding that the patient/guarantor, not your insurance company is responsible for payment of this account.

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