I understand that I may have an obligation to obtain a referral from my Primary Care Physician prior to making an appointment. I acknowledge that if I do not have a required referral for today’s visit, I am responsible for the services rendered should this be denied by my insurance company.
Please note that the Patient can be accompanied by one person in the exam room to ensure proper treatment and less distractions for the provider and the patient.
With my signature below, I voluntarily give consent for myself and/or my child to be examined and treated by the clinicians of Neurovations Clinic. I authorize my insurance company(s) to pay benefits directly to Neurovations Clinic and I agree that a reproduced copy of this authorization will be as valid as the original. I understand that I am responsible for any amount not covered by my insurance or any amount for a patient for which I am the guarantor. I agree that I will be responsible for any collection agency or attorney fees incurred. I understand that by signing below, I am giving written consent for the use and disclosure of protected health information for treatment, payment, and healthcare operations.
Please note that the Patient can be accompanied by one person in the exam room to ensure proper treatment and fewer distractions for the provider and the patient.
