I authorize the release of any medical information necessary to process claims for payment. I permit a copy of this authorization to be used in place of the original. I authorize direct payment of benefits to the physician for services rendered. I realize I am responsible for payment of charges not covered by insurance. I certify that the information I have reported with regard to my insurance coverage is correct.
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I understand that I have the right to make informed decisions about my health care treatment. I understand that Pineapple Health-Rejenesis specializes in Integrative and Preventive Medicine. I further understand that Dr. Kevin Chan is a recognized specialist in this area. I agree to have Dr. Kevin Chan and his providers and staff do tests and treatments they believe are needed for my care, including my annual physical. These may include but not limited to vital signs, ekgs, spirometries, x-rays, scans, expanded lab tests, allergy testing, lifestyle modifications, physical therapies, acupuncture, medications, hormone replacement therapies, as well as nutritional and herbal supplementations. I know other treatments or tests that may have more risks will be explained to me so I can give informed consent for them if I need them.
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