2. Appointment Schedule
4. Appointment Results
5. Payment Information
the link to another tab to make payment upon submission of your form.
6. Employee State Identification Card / Driver's License
7. Employer's Address
8. Terms of Service
I give permission to Brij Health 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.
I give permission to Brij to perform a wellness and/or preventative health screening. I understand that I am solely responsible for following up with my personal physician or other healthcare provider about the results of my screening. In performing the wellness screening, Brij does not assume any responsibility for ongoing treatment or management of care.
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 Health 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 Health 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
Your name and signature below indicate that you have been made aware of Brij’s Notice of Privacy Practices (NOPP) on the date indicated. You understand that the NOPP is posted in the center and a copy will be provided to you if you request it. If this is your first date of service with Brij, please indicate this to the front desk receptionist and he/she will provide you a copy of the NOPP. If you have any questions regarding the information in Brij’s Notice of Privacy Practices, contact Brij’s Privacy office at 952-479-0814 or email@example.com
9. Employee Signature
TO BE COMPLETED BY THE PROVIDER