Our office requires 24-hour notice for cancellation of ANY appointment. If appropriate notice is not given or you No Show you will be charged a $50 fee.
Our Office will file insurance for all reimbursable services, to both primary and secondary insurance carriers. Please remember that you are responsible for all deductible, co-pay, and non-covered service amounts.
I authorize use of this form on all my insurance submissions and request payment of authorized Medicare benefits and/or private insurance benefits be made to Eric L. Hensen, D.O., P.A. for services rendered to me. I authorize release of information to all my insurance companies.
I understand that I am responsible for my bills.
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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