- I give permission to [name of clinic or doctor’s office] to file for insurance benefits to pay for the care I receive.
- I understand that:
- [name of clinic or doctor’s office] will send my medical information to my insurance company.
- I must pay my share of the costs.
- I must pay for the cost of the care I receive if my insurance company does not pay or I do not have insurance.
- I understand:
- I have the right to say not to any treatment or procedure.
- I have the right to discuss all medical treatments with my provider.
- I have the right to ask about costs before I am treated.
Patient’s Signature and Date
Parent or Guardian Signature (for children under 18) and Date