2026 Consents

RECEIPT OF NOTICE OF PRIVACY PRACTICES AND NOTICE OF NON-DISCRIMINATION: My signature below indicates that I have received and/or reviewed a copy of my physician’s Notice of Privacy Practices and Notice of Non-Discrimination.

INITIALS:      __________ 

PAYMENT POLICY: I will be responsible for paying my annual deductibles, copayment and charges for any non-covered medical and cosmetic services at time of service. I understand that I am responsible for any deductibles, coinsurance, co-pays and services deemed not medically necessary by my insurance carrier.
I understand that if I do not show up for my scheduled appointment or do not call within 24 hours to cancel/reschedule, I will be assessed a $75.00 fee for a regular appointment or $150.00 for a surgery appointment.
I further understand that if I present a check that is returned to FRDA for insufficient funds, I will be assessed at $45.00 insufficient funds fee.

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INITIALS:

OUTSIDE LAB CHARGES: If your provider takes a biopsy or culture, this specimen will be sent to an outside laboratory for processing and testing.  If that is the case, you will receive a bill from that lab.  Those charges would be in addition to your treatment costs and would be due and payable to the lab that is chosen.

I understand that all outside lab charges will be billed to me separately.

INITIALS:      ________

AUTHORIZATION TO USE CELL NUMBER AND EMAIL ADDRESS FOR APPOINTMENT REMINDER INFORMATION:    By supplying my home phone number, mobile phone number, email address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach and messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, a missed appointment or overdue wellness exam.   I also authorize my healthcare provider to disclose to third parties, who may intercept these messages, limited protected health information (PHI) regarding my healthcare events.  I consent to receiving multiple messages per day from my healthcare provider, when necessary.  I consent to allowing detailed messages to be left on my voice mail, answering system, or with another individual, if I am unavailable at the number provided by me.

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INITIALS:

Patient or responsible party signature:  

Printed Name:                                                                                                                             Date:                     	 

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