Authorization for Medical Treatment and Financial Responsibility

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Authorization for Medical Treatment

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

• Physical examinations and assessments
• Diagnostic procedures and tests
• Medical treatments and interventions
• Preventive care services
• Administration of medications and vaccines
• Referrals to specialists when deemed necessary

Financial Agreement

1. I understand that I am financially responsible for all charges, whether covered by insurance or not.
2. I authorize my insurance benefits to be paid directly to [Practice Name].
3. I understand that I am responsible for:
   • Co-payments at the time of service
   • Deductibles as determined by my insurance plan
   • Any services denied by my insurance company

Communication Consent

I authorize [Practice Name] to contact me via:

• Phone calls
• Text messages
• Email
• Patient portal

Emergency Contact

Name: _________________________ Relationship: _____________ Phone: ________________________

Signatures

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

This authorization remains in effect until revoked in writing.