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*1 New Patients: Consent for Treatment & Payment & Acknowledgements

Consent to Medical Care

The undersigned consents to any laboratory, imaging, anesthetic, medical, surgical or emergency treatment and / or clinic services rendered the patient under the instruction of the Provider. The patient understands that no guarantee or assurance has been made as to the results that may be obtained during treatment. The patient also consents to observation of the patient during administration of medical treatment, surgical or diagnostic procedures of the purpose of education of students whose presence is deemed appropriate by the attending Provider.

Release of Patient Information

The undersigned hereby consents that Home Towne Family Medicine may release to the guarantor?s insurance company, or any third party payer, pertinent information related to the medical treatment including: HIV testing and treatment, sexually transmitted disease testing and treatment, psychiatric, alcohol and drug treatment records in order to secure contractual payments of services rendered (unless a restriction has been requested, the see restriction agreement).

Assignment of Insurance Benefits

In the event the patient is entitled to medical benefits of any type whatsoever arising out of any policy of insurance insuring the patient or any other party liable to the patient, such benefits are hereby assigned to Home Towne Family Medicine for application to patient?s bill. The patient my be responsible for 100 % of charges not covered by this assignment. Patients eligible for Medicare hereby authorize Home Towne Family Medicine to bill and collect from Medical directly. Any charges not covered by Medicare or any supplementary insurance may be the responsibility of the patient.

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That he / she has read the foregoing, and is the patient, or is duly authorized by the patient as his / her legal representative to execute the about and accept its terms. If competent, the patient should sign in space indicated. If a minor, or incapable of signing, responsible representative should sign in the space indicated.

The Undersigned Certifies

Permission to Treat Minors

I, the undersigned, give permission to the Home Towne Family Medicine providers to treat for any medical or surgical problem that may arise during my absence.

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