Common Contracts
1 similar Patient Information Form contracts
IFPain AssociatesPatient Information Form • January 22nd, 2023
For and in consideration of services rendered, I agree to make payment to IFPain Associates when billed for any and all charges not covered by valid insurance benefits. I authorize payment directly to IFPain Associates for health insurance benefits payable to me under terms of my policy but not to exceed the balance due for services performed during this period of treatment. IFPain Associates may seek, release and verify all or part of my medical and/or financial records to any person, corporation or government agency which is or may be liable under a statute, regulation or contract to IFPain Associates, myself, a family member or my employer for all or part of the IFPain Associates charge.
