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Section - Patient Information


     

 

                    

 




Section - Ethnicity and Preferred Language





Section - Responsible Party





Section - Patient Insurance









Section - Certification and Assignment


To the best of my knowledge, the information herein is complete and correct. I understand that it
is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
I will not hold my doctor or any members of his/her staff responsible for any errors or omissions
that I may have made in the completion of this form.

I Certify that I, and/or my dependents have insurance coverage with and assign
directly to Your Doctors Care       all insurance benefits, if any, otherwise payable to
me for services rendered. I understand that I am financially responsible for all charges whether or not paid by
insurance. I authorize the use of my e-signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance
Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the
benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the
date signed below.

Name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient






CONFIDENTIAL







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