EMERGENCY CONTACT INFORMATION

List someone we may contact in case of an emergency

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EMERGENCY CONTACT INFORMATION

List someone we may contact in case of an emergency

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ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

By signing below, I acknowledge that I have received a copy of the Notice of Privacy Practices. The notice describes how my health information may be used or disclosed. I understand that I should read it carefully. I am aware that the notice may be changed at any time and that i may obtain a revised copy of the notice at the clinic location where I receive healthcare services. Click here to read the ,a href="https://pca-nwa.com/hipaa/">Notice of Privacy Practices prior to signing below.

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AUTHORIZATION FOR INSURANCE PAYMENT

My signature below indicates that I agree to authorize payment of insurance benefits to the service provider, authorize the release of any information necessary to process insurance claims, and accept payment responsibility of the portion of the bill which insurance does not cover.

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