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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