AUTHORIZATION AND RELEASE
Authorization for treatment: I voluntarily consent to the administration and cost of medical and surgical procedures for myself or my dependent.
Assignment of insurance benefits: I authorize payment direct to NJ Doctors Urgent Care, LLC for all benefits otherwise payable to me.
Guarantee of Payments: I understand that I am financially responsible and agree to pay all charges that are not paid or billed to insurance or any other third party payer. I understand that I must pay in full today for all services rendered unless my insurance is accepted. I also understand that if my insurance accepted, I must pay all applicable insurance co pays, coinsurances and deductibles today. If you are unable to verify my insurance at time of services, I will in full for all services.
Release of Records: I authorize NJ Doctors Urgent Care, LLC to release (verbal or in writing) confidential medical information to any person or entity including my insurance carrier, employer if treatment is related to employment purposes, or other health care operation which may be liable to me or my practitioners for charges for this treatment and for quality management, utilization review, transfer, and follow up purposes.
Receipt of Privacy Practices: I acknowledge that I have received and read the Notice of Privacy Practices of NJ Doctors Urgent care, LLC. I understand that copy of this agreement may be used with the same effectiveness as the original.
CONSENT FOR TREATMENT: I, the undersigned, consent to the care and treatment by the attending physician, his/her associates or assistants. I acknowledge that no guarantees have been made as to the effect of such treatment.
