INSURANCE INFORMATION

PAYMENT POLICIES

You are financially responsible for anything insurance does not cover. All copays are due and payable at each visit. The amount your insurance will allow and pay for and your financial responsibility is determined by your insurance company and the policy you have chosen. Your claim will be processed according to the benefits of your insurance plan. The deductible, co-insurance and co-pay are your financial responsibility. It is your responsibility to understand your insurance plan. $5 Fee for Co-pays not paid at the time of service. $50 No Show Fee for any Missed Appointment that was not cancelled or rescheduled 24 hours prior to the appointment. Please be considerate and call at least 24 hours before your appointment if you cannot come in. $35 NSF charge for any returned check from the bank. If you are a private patient all charges are due at the time of the visit. We do not send a statement to private pay patients

PRESCRIPTION POLICY

Please do not wait until your last pill to call for a refill. There is a 72 hour turn around for prescription refills. If you have not seen the Physician in six months, the prescription will be Denied.

PATIENT MEDICAL HISTORY

FAMILY HISTORY

Please indicate if any of your immediate relatives have had any of the following by checking in the appropriate box.

SOCIAL HISTORY

Surgical History

Please list any hospitalizations. surgeries. fractures or major illnesses you have had.

MEDICAL HISTORY

Have you ever had any of the following

Medications:

List any medications you are currently taking (please include over the counter medications): PLEASE PRINT LEGIBLY - NO CURSIVE PLEASE

MEDICAL SERVICES AGREEMENT

Medical Consent: I consent to any treatments or procedures which may be performed on an outpatient basis (including emergency treatment or services), which may include but are not limited to medications, injections, taking of medical photographs, laboratory procedures, and/or x-ray examinations provided to me under the general and special instructions of the ARNP, staff, or other health care providers of Absolute Medical Healthcare LLC assisting my care. Financial Agreement: I understand that all charges are due at the time of service. I agree to pay for all charges for healthcare services and professional services provided to me by ARNP and other healthcare professionals. Acceptable forms of payment include Cash, Visa, MasterCard, Discover, and American Express. If I am a non-insured patient, I agree to pay for my visit in full at the time of service .. Insurance Authorization and Release: I request the payment of authorized benefits, including Medicare, and any other government sponsored program, private insurance, and any other health plans to be made to Absolute Medical Heathcare LLCnished by that provider. To the extent necessary to coordinate my health care or determine liability for payment and to obtain reimbursement for services rendered, I authorize Absolute Medical Healthcare LLC to disclose portions of or all of my records, including my medical records to any person or corporation which is or may be liable for all or any portion of Absolute Medical Healthcare LLC, including but not limited to insurance companies, health care service plans, governmental agencies, or worker's compensation carriers. Release of Medical Information: I hereby authorize Absolute Medical Healthcare LLC to release any information in my chart to any practitioner, doctor, hospital, or medical institution to which I may be referred to assist in my care. Additionally, I authorize any healthcare office to provide a copy of my medical records to my Primary Care Physician (PCP) to allow for continuity of care. Notice of Privacy Practices: By signing this form, you acknowledge receipt of the "Notice Of Privacy Practices" of Absolute Medical Healthcare LLC. Our "Notice of Privacy Practices" provides information about how we may use and disclose your protected health information. We encourage you to read it in full. Our "Notice of Privacy Practices" is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting Absolute Medical Healthcare LLC 2536006007. Pharmacy: I understand that, for my convenience, Absolute Medical Healthcare LLC use selected pharmacy, a prescription can be provided to me at no additional charge. Personal Valuables: Absolute Medical Healthcare LLC shall not be liable for the loss of or damage to any money, documents, jewelry, glasses, dentures, furs, or other articles of unusual value and shall not be liable for loss or damage to any personal property. Absolute Medical Helathcare LLC A medical corporation and the patient or the patient's representative, hereby enters into this agreement The undersigned certifies that he/she has read and agree to the foregoing, and is the patient, the patient's representative or is duly authorized by the patient as the patient's general agent to execute the above and accept its terms.

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