Assignment and Release Form Please sign below for authorization of payment for contracted insurance plans and the release of any medical information necessary for your insurance company in conjunction with federal privacy laws. Our office will provide you with a thorough receipt for reimbursement of non-contracted insurance plans. In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose health information in order to treat you, obtain payment for our services, and conduct healthcare operations involving our practice. The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. Health Information Protection* I acknowledge that I have read the office's Notice of Privacy Practices By signing below you acknowledge that you accept responsibility for payment of our services and materials you receive. Payment for professional services is expected at the time services are provided. We accept cash, check, Visa, MasterCard, American Express and Discover. Our policy regarding orders for materials is that we require a minimum of a 50% deposit at the time the order is placed and balance due upon delivery. All professional services are non-refundable. All materials returned are subject to a 20% restocking fee. Patient Name First Last Patient SignatureDate MM slash DD slash YYYY
