COMPLETE AUTHORIZATION
The patient is responsible for all fees, regardless of insurance coverage. It is customary to pay for services when rendered, unless arrangements are made in advance.
I hereby request and consent to diagnostic procedures, including CHDP examinations, XRAYS, blood tests, medical treatments, including immunizations.
I (self or parent/legal guardian) hereby authorize Allied Health Solutions Medical Group to furnish information to insurance carriers concerning my illness and treatments and I hereby assign to the doctor, all payments for medical services rendered. I agree to settle all claims by arbitration.
Required
Required
Required
Required
Required
|
Male
|
|
Female
|
Required
Required
|
Caucasian
|
|
Black
|
|
Indian
|
|
Asian
|
|
Hispanic
|
|
Other
|
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
|
Emergency Contact
|
Required
Required
Required
|
Medical Insurance Information
|
Medical Insurance Information
MEDICAL INSURANCE (PRIMARY)
Required
Required
Required
Required
Please select file to upload.
Required
Please select file to upload.
