Please fill out this one page intake form.
I hereby authorize payment directly to Doctors Urgent Care for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.
Fees incurred in Collection or Litigation of any unpaid balances will become the responsibility of the patient or guarantor. I irrevocably assign my benefits to Doctors Urgent Care including the right to sue my insurance company for denials or reductions. I authorize the above medical provider to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Signature of Responsible Party