Thank you for choosing Healthy Living First Medical Group as your healthcare provider. We appreciate your trust and are committed to providing you with the best care possible. Please read and sign this form to confirm that you understand our financial policies.
Patient Financial Responsibilities
The patient (or legal guardian, if the patient is a minor) is responsible for paying for all services provided.
• We will gladly bill your insurance as a courtesy. However, you must provide accurate and up-to-date insurance information. You are responsible for any charges not covered due to incorrect or expired information.
You are responsible for any co-pays, co-insurance, deductibles, or non-covered services at the time of your visit. For your convenience, we accept cash, checks, and most major credit cards.
Additional charges may apply for the following:
◦ Returned checks
◦ Missed appointments without 24-hour notice ◦ After-hours phone calls requiring medical advice, prescriptions, or treatment ◦ Copies of medical records
◦ Completion of forms (such as disability or work forms)
◦ Costs related to collection of unpaid balances
Authorizations and Agreements
By signing below, you agree to the following:
I authorize Healthy Living First Medical Group and its staff to share my medical information with my insurance company and other healthcare providers involved in my care, when necessary for billing and treatment purposes.
I understand that some sensitive information requires my specific permission to release. Please check any that apply: [ ] Drug or alcohol treatment records [ ] HIV/AIDS testing or results [ ] Mental health or psychiatric treatment records
I authorize payment of insurance benefits directly to Healthy Living First Medical Group for services provided.
I understand that I am financially responsible for any charges not covered by insurance.
I allow Healthy Living First Medical Group to contact me by phone, mail, or email using the information I provided.
