GENERAL CONSENT FOR TREATMENT AND AUTHORIZATION FOR INSURANCE PAYMENT

I authorize the Enterprise Valley Medical Clinic provider to perform such diagnostic, medical and/or surgical procedures as may be necessary for proper health care. I also give permission for administration of medication and immunizations as may be necessary for that treatment. I have read all of the information on the registration form and have completed it to the best of my ability. I certify that this information is true and correct to the best of my knowledge. I WILL NOTIFY ENTERPRISE VALLEY MEDICAL CLINIC OF ANY CHANGES IN MY HEALTH STATUS OR ANY OF MY DEMOGRAPHIC/INSURANCE INFORMATION.

I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatment and examination by Enterprise Valley Medical Clinic.

I consent to the release of medical information to other institutions or agencies accepting the patient for medical or institutional care, and consent to the release of medical information to patient's insurer and give permission to release data (both medical and personal) to such government agencies as it is required of Enterprise Valley Medical Clinic by law, rules, regulations, or by consent.

I consent to the release of medical and financial information for auditing purposes.

I hereby authorize payments to Enterprise Valley Medical Clinic of benefits due to me in my pending claim and/or MAJOR MEDICAL BENEFITS, otherwise payable to me, but not to exceed the health center and/or physician regular charges for this period of treatment. I agree that a copy of this authorization is as valid as the original. I understand that if my insurance does not approve the charges for this/and future visits, I am fully responsible to Enterprise Valley Medical Clinic for payment.

BY SIGNING THIS DOCUMENT, I ATTEST THAT ALL INFORMATION IS TRUE AND CORRECT AND I WILL NOTIFY ENTERPRISE VALLEY MEDICAL CLINIC OF ANY CHANGES TO MY INSURANCE, INCOME OR CONTACT INFORMATION.

I have read and/or been furnished a copy of the \"Notice of Privacy Act\" for Enterprise Valley Medical Clinic.

I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance of my account and for professional services rendered. I agree to pay all attorney's fees, court cost, filing fees, including charges or commissions that may be assessed to us by any agency retained to pursue this matter which may be as muchas 50% of the principle owing. I/we further agree to pay interest at the rate of 1.5 percent per month (18% year).

I Agree

I Agree