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Registration Form

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Patient Information

RESPONSIBLE PARTY INFORMATION (PARENT OR LEGAL GUARDIAN IF PATIENT IS CHILD)

EMERGENCY CONTACT

APPROVAL TO SHARE HEALTH INFORMATION

PRIMARY INSURANCE

SECONDARY INSURANCE

ASSIGNMENT AND RELEASE

The undersigned patient, legal guardian or power of attorney certifies that above entries are correct and agrees as follows: Authority is granted to Angela Merlo, MD to order tests and render treatment to the above named patient. Authority is granted to Angela Merlo, MD to release healthcare information to the above named insurance company(ies) and their agents for the purposes of determining benefits and obtaining payment for services. The signature on this document authorizes Angela Merlo MD to submit claims for services rendered without obtaining a signature on each and every claim. Authority is granted for insurance company(ies) including Medicare to pay directly to Angela Merlo, MD for services rendered with the understanding that all payments will be credited to patient's account. The undersigned agrees to be financially responsible for charges for all services rendered including non-covered or unauthorized services. The undersigned also agrees to pay any collections or attorney's fees above and beyond the past due amount should there be a past due amount.

Verification