I hereby acknowledge that I am aware that FARAH MEDICAL , LLC, will occasionally other doctors on call for them.

I hereby authorize FARAH MEDICAL,LLC  to release any medical information to insurance companies, attorneys, or other related companies for the establishment of medical bills due to this medical office.

I authorized and I hereby assign payment to FARAH MEDICAL,LLC  , for all medical insurance benefits. I also understand that my responsibility for payment of any and all load no less than the allowance payable.

* PAYMENT IS DUE IN FULL WHEN DO THE SERVICES. *

I understand and agree that, regardless of insurance status, I am responsible for the balance in full and explain any professional service rendered, including any fees incurred for the collection of debt.

I certify that the information provided is true and correct and to the best of my knowledge.

I have received and understood this information for privacy practice brought by this office. The notice provides in detail the use and information-disclosure of my protected health, my individual rights, as I can exercise these rights and the legal rights of practice in respect to this information.

 

I understand that this practice reserves the right to change the terms of the notice of privacy practices and to make changes to all information referred to this practice controls protected my health. If there are changes to this policy, this practice will provide me a revised privacy notice, if I wanted to.

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