Please read and answer the following:
1. Please note that Co-pays are collected at the time of visit.
2. I authorize the release of any medical records or other information necessary to process this claim. I understand that all medical records will be stored on a secure, encrypted server for 7 years. I understand that my data is collected, stored and shared as needed and is handled in compliance with the data protection law.
3. I understand that all treatment fees will be billed directly to my insurance company provider. Please note that we charge the SHIF customary health insurance charges.
4. I authorize Novo Clinic LTD. to verify my health insurance benefits. I will be responsible for all co-pays/co-insurance and deductibles that may apply.
5. I understand that I will be responsible for all rejected amounts billed to my insurance provider for services rendered by the medical practitioners of Novo Clinic LTD.
6. I understand that any amounts outstanding for more than 90 days will be send for debt collection through the appropriate channels.
7. I grant permission for licensed medical practitioners at Novo Clinic LTD to perform such examinations and medical treatments as may be professionally deemed necessary or advisable for appropriate evaluation and treatment of my condition. I understand that I will be given all available pertinent information prior to treatment being rendered. I will be given the opportunity to ask questions and to have them answered to my satisfaction.
8. I understand that I may decline treatment at any time
Consent for Echolight Ultrasound Bone Density Test
I understand that the Echolight ultrasound bone density test is a non-invasive diagnostic screening used to assess bone density.
I acknowledge that this test does not replace clinical diagnosis and that results should be interpreted by a qualified healthcare professional.
I consent to undergo this procedure.
