General Financial Policy, CC Authorization, Consent to 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information at the top of the form, including your name and contact details. This ensures that all communications regarding your financial policy are directed to you.
3. Review the Financial Policy section carefully. Acknowledge your understanding of payment responsibilities by checking the appropriate box or signing where indicated.
4. In the Insurance Coverage section, provide details about your insurance provider. If applicable, include any necessary policy numbers and ensure that you understand your coverage limits.
5. For the Managed Care Referral Process, indicate whether a referral is required for specialist visits. If so, confirm that you will obtain this from your primary care physician before scheduling an appointment.
6. Fill out the Payment of Post Visit Balances section by agreeing to pay any outstanding balances within 30 days of receiving a statement.
7. Acknowledge the No Show and Cancellation Policy by signing in agreement. This confirms your understanding of potential fees associated with missed appointments.
8. Finally, complete the Authorization of Care section by signing and dating it. If applicable, have a legal representative sign on behalf of a minor or incapacitated patient.

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