Authorization for Medical Treatment and Financial Agreement

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: _____________________

Authorization for Medical Treatment

I, the undersigned, hereby authorize [Practice Name] and its medical providers to provide medical care and treatment, including but not limited to:

• Physical examinations and medical assessments
• Diagnostic procedures and laboratory tests
• Administration of medications and vaccines
• Medical treatments deemed necessary for my health care

Financial Agreement

I understand and agree to the following terms:

1. I am financially responsible for all charges incurred
2. Insurance claims will be filed on my behalf when applicable
3. Co-payments and deductibles are due at time of service
4. Outstanding balances must be paid within 30 days

Release of Information

I authorize the release of medical information necessary to:

• Process insurance claims
• Coordinate care with other healthcare providers
• Comply with legal requirements

Emergency Contact Authorization

I authorize the following person to receive information about my care:

Name: _________________________ Relationship: _____________ Phone: _________________________

Signatures

Patient/Guardian Signature: _________________ Date: _________ Witness Signature: ________________________ Date: _________

This authorization remains in effect until revoked in writing.