I hereby authorize the offices of Primary Care House Calls, to release
any medical information required during examination and treatment to my
insurance, and I permit payment to Primary Care House Calls, from my insurance
company for any benefits due for their services rendered. I recognize and
accept responsibility for services rendered regardless of insurance coverage.
This includes but is not limited to coinsurance, copayment, deductible,
and noncovered services.
I understand that I am responsible for all charges incurred regardless
of the insurance status. I agree to pay for services incurred after the
patient has been charged for the office visit, such a labs, radiology,
medical supplies, etc. I agree to pay my bill in full for services rendered
by Primary Care House Calls providers.