If the patient is not the responsible party for the insurance or insurance is through spouse please complete the following . Otherwise please skip to the end of the form and read disclosure and submit.
Consent for Treatment : By Submitting this form you hereby consent to examination and treatment by the physician/medical provider and the performance of any procedure that is deemed necessary. You here by authorize payment directly to this medical office from your medical benefits. You also acknowledge that you are responsible for any deductibles, co-pays or other payments for non-covered services. . You authorize Cary Adult Medicine to release Medical Information acquired in the course of your treatment necessary to process insurance claims