I voluntarily consent to receive medical and health care services that may include diagnostic procedures, examination, and treatment. I hereby assign, transfer, and set over to Care Today Clinic all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy.
I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization.
I understand that I am financially responsible for all charges whether or not they are covered by insurance.
© 2014, Care Today Urgent Health
Opulus Theme | Powered by WordPress