Initial:    I hereby consent to and authorize the performance of medical or minor surgical procedures, including emergency life-saving measures, which may be considered necessary or advisable by the healthcare providers that include care provided by nurse practitioners and physician assistants of Legacy Partners for Equitable Healthcare.

Initial:    I authorize payment of medical benefits to Legacy Partners for Equitable Healthcare providers or supplier for medical services, to include government assigned benefits. I authorize the release of any medical or other information necessary to process this claim.

Initial:    Financial Arrangement: I hereby agree that I am financially responsible for charges incurred at the time of rendered services. I acknowledge that I have received the financial policy. Should my account be referred to an attorney or agency for collection, the undersigned shall pay reasonable attorney fees and collection expenses.

Initial:    I hereby acknowledge that I have received the HIPAA Notice of Privacy Practices for Personal Health Information and New Patient Welcome Letter.