(We will make a copy of your Insurance Card. However, we do request that you fill in the information below)
RELEASE OF MEDICAL INFORMATION
I authorize Tri-City Family Medicine and Urgent Care Clinic, PLLC, to release the medical records concerning my son/daughter/self to any physician, hospital, or agency involved in the care of the patient listed.
ASSIGNMENT OF MEDICAL BENEFITS
I authorize my insurance carrier to assign all surgical and or medical benefits, if applicable, to Tri-City Family Medicine and Urgent Care Clinic, PLLC. I also authorize release of medical information necessary to process all medical insurance claims.
I understand that it is my responsibility to obtain a referral through my primary care physician’s office if required by my insurance company. Failure to do so will result in charges being billed directly to myself.
I HAVE READ, UNDERSTAND, AND AGREE TO ABIDE BY THE ABOVE RELEASE OF MEDICAL INFORMATION. IT IS IMPORTANT TO PROVIDE US WITH ACCURATE INFORMATION REGARDING YOUR PRIMARY & SECONDARY INSURANCE. IF THE INFORMATION IS INACCURATE, YOU MAY BE HELD LIABLE FOR YOUR VISIT. BY SIGNING BELOW, YOU ARE INDICATING THAT THE INFORMATION ABOVE IS CORRRECT.