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I give permission to Brij to perform the following services that the physicians and other non‐physician providers and assistants may deem to be necessary:(a) medical, surgical, and diagnostic (e.g.: including, but not limited to, x‐rays, blood draws, and laboratory tests) processes, treatments, and procedures; (b) administration of injections, medications, and immunizations (with immunizations to occur after my receipt of any applicable vaccine information statements (“VIS” or “VISs”)); and(c) completion of medically appropriate tests for communicable and other diseases.
Brij will submit claims to my insurance carrier as well as medical records needed to evaluate the claims for payment. I further assign payment of benefits, otherwise payable to me, to be made payable to Brij.
I understand that I am financially responsible for all charges not covered by my insurance
Payment made today will be paid by:
Patient Pay – I will be paying today using: Cash Check VISA MasterCard Discover Debit Card American Express
Insurance – I will present my insurance card and an approved form of ID.
Unless you are here for employer paid services, you will be responsible for either full payment or payment as indicated by your insurance plan. If Brij has a contract with your insurance company we will file today’s charges with that insurance company. You will be responsible for your co‐payment and/or deductible, and the cost of any services not covered by insurance. You may receive a bill from Brij for any unpaid balance.
I understand that I am financially responsible for all charges not covered by my insurance. Initials If you do not have insurance coverage or Brij does not have a direct contract with your insurance company, you will be required to pay in full for your visit today. You can expect to pay an initial payment for medical care/treatment based on posted pricing in the center. This will be collected at check‐in.
If your treatment requires more complex evaluations, lab tests, vaccines, medications, X‐rays, or supplies, you will be charged for those in addition to the appropriate office visit fee. These fees will be collected after service and treatment have been provided.
I do not have insurance and I acknowledge that I am responsible for all costs. Initials