Patient History Form

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Family History

 

BY SUBMITTING THIS FORM, I HEREBY AUTHORIZE SEALE HARRIS CLINIC, P.C. TO RELEASE ANY AND ALL INFORMATION ACQUIRED IN MY EXAMINATION, TREATMENT AND DIAGNOSIS TO MY INSURANCE CARRIERS AND TREATMENT PHYSICIANS. IF I AM COVERED BY INSURANCE I AGREE TO SHOW MY CARDS AND SUPPLY ANY FORM NECESSARY TO SEALE HARRIS CLINIC AT EACH VISIT. I AM ALSO RESPONSIBLE FOR LETTING SEALE HARRIS CLINIC KNOW IN WRITING OF ANY CHANGES IN MY DEMOGRAPHIC OR INSURANCE INFORMATION. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES FOR SERVICES PERFORMED AT SEALE HARRIS CLINIC, P.C. I ALSO UNDERSTAND THAT ANY AND ALL OF MY INFORMATION PERTAINING TO TREATMENT, PAYMENT AND OPERATIONS OF THE PRACTICE MAY ONLY BE RELEASED TO INVOLVED PARTIES.

I HEREBY ASSIGN AND AUTHORIZE PAYMENT DIRECTLY TO SEALE HARRIS CLINIC, P.C. ANY MEDICAL AND SURGICAL BENEFITS OTHERWISE PAYABLE TO ME. SHOULD ANY INSURANCE PAYMENT BE RECEIVED THAT IS LESS THAN THE PHYSICIAN'S USUAL CHARGE FOR THE SERVICES PROVIDED, I WILL BE RESPONSIBLE FOR THE DIFFERENCE. I UNDERSTAND THAT IF MY INSURANCE PROVIDER DENIES PAYMENT FOR ANY SERVICE FOR ANY REASON I WILL BE RESPONSIBLE FOR THOSE CHARGES.

 

I ALSO AGREE TO PAY ALL COST OF COLLECTION INCLUDING, BUT NOT LIMITED TO COLLECTION FEES, REASONABLE ATTORNEY'S FEES, AND WAIVER ALL CLAIMS OF EXEMPTION UNDER THE LAW OF THE STATE OF ALABAMA. UNTIL MY ACCOUNTS ARE FINALLY SETTLED, I GIVE MY DIRECT CONSENT TO RECEIVE COMMUNICATIONS REGARDING MY ACCOUNTS FROM ANY SERVICERS AND ANY COLLECTORS OF MY ACCOUNTS, THROUGH VARIOUS MEANS SUCH AS 1) ANY CELL, LANDLINE, OR TEXT NUMBER THAT I PROVIDE, 2) ANY EMAIL ADDRESS THAT I PROVIDE, 3) AUTO DIALER SYSTEMS, 4) VOICEMAIL MESSAGES, AND OTHER FORMS OF COMMUNICATIONS. FORMS MUST BE SIGNED AND DATED BY PATIENT OR RESPONSIBLE PARTY.