Acknowledgment of Receipt of Privacy Policies

Please correct the errors described below.

All professional services rendered are charged to the patient. We do, as a courtesy, bill your insurance company. If you have no insurance coverage it is customary to pay for services when they are rendered, unless other arrangements have been made in advance. Ultimate responsibility of payment for services is the patient’s.

For our Medicare patients we accept MEDICARE ASSIGNMENT as well as submit all claims to your supplemental insurance.

I authorize the physician to release any information required in the course of examination and permit payment directly to Pineapple Health for any services rendered. Regardless of insurance coverage, I recognize and accept responsibility for any remaining balance.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Acknowledgement of Receipt of Privacy Notice

I understand that I am entitled to a copy of this notice of Privacy Practice

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