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- I (patient name) give permission for [practice name] to give me medical treatment.
- I allow [practice name] to file for insurance benefits to pay for the care I receive.
I understand that:
- [practice name] will have to send my medical record information to my insurance company.
- I must pay my share of the costs.
- I must pay for the cost of these services if my insurance does not pay or I do not have insurance.
- I understand:
- I have the right to refuse any procedure or treatment.
- I have the right to discuss all medical treatments with my clinician.
Patient's Signature Date
Parent or Guardian Signature Date
(for children under 18)
Print name
