330 W 42nd St. 212-695-4444
919 2nd Ave. 212-935-3333
380 2nd Ave. 212-826-7777
Authorization for treatment: I voluntarily consent to the administration and cost of medical and surgical procedures for myself or my dependent.
Assignment of Insurance Benefits: I authorize payment directly to The Doctors' Office for all benefits otherwise payable to me.
Guarantee of Payment: I understand that I am financially responsible and agree to pay all charges that are not paid or billed to insurance of any other third party payer. I understand that I must pay in full today for all services rendered unless my insurance is accepted. I also understand that if my insurance is accepted, I must pay all applicable insurance co pays, coinsurances, and deductibles today. If you are unable to verify my insurance at time of service, I will pay in full for all services.
Release of Records: I authorize The Doctors' Office to release(verbal or in writing) confidential medical information to my insurance carrier, employer if treatment is related to employment purposes, or other health care operations which may be liable to me or my practitioner(s) for charges for this treatment and for quality management, utilization review, transfer, and follow up purposes.
Receipt of Privacy Practices: I acknowledge that I have received and read the Notice of Privacy Practices of The Doctors' Office. I understand that a copy of this agreement may be used with the same effectiveness as the original.
I give permission to MedRite Urgent Care to:
Check in is easy and comfortable. We have several exam rooms, an X-Ray department, and an on-site lab so you will receive high quality medical care that's both fast and convenient.