I agree to the following:
1. Co-Pays are collected at the time of the 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 SHIC customary health insurance charges.
4. I authorize NovoClinic 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 NovoClinic.
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 NovoClinic to perform such examinations and medical treatments as deemed necessary or advisable for appropriate evaluation and treatment of my condition.
8. 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.
9. I understand that I may decline treatment at any time.
