Betty H Yao, MD APC

Patient's Full Name * Date of Birth *

Agreement to pay / Authorization for insurance payment: I agree to pay for all fees or my legal portion not covered by medical insurance for the above mentioned patient, at the time of service. I also agree to be responsible for any fees required to collect payment for services including attorney and court costs,collection agency fees, pre-judgement and/or post-judgement interest at the current legal rate. I authorize my insurance company to make payments to Betty H. Yao, MD.

Patient or Legal Guardian (if under 18) Signature * Date: *

Medical Records Release: If it is necessary for any part of my medical records to be sent to another health provider for medical reasons, I authorize Betty H. Yao, MD APC to do so. If it is necessary for Betty H. Yao, MD APC to request my medical records from another physician or healthcare organization, I authorize that any part of my medical records be given to Betty H. Yao, MD APC. I also authorize the release of medical information necessary to process my claim to my insurance company,Workman's Compensation Plan, Social Security, Medicare, Medicaid, or any representatives acting on behalf. I permit a copy of this authorization to be used in place of the original. I hereby release Betty H. Yao, MD APC from all legal liability that may arise from the disclosure of such information.

Patient or Legal Guardian (if under 18) Signature * Date *

Privacy Policy: I acknowledge that I have received version (1) of Betty H. Yao, MD APC's, Notice of Privacy Practices. I realize that Betty H. Yao, MD APC makes reasonable efforts to keep the communications of protected health information confidential therefore my medical information will be disclosed only with my permission signature under the "Medical Records Release" statement above. I understand there are exceptions under which any healthcare provider may disclose my health information without my authorization, as listed in the Notice of Privacy practices.

Patient or Legal Guardian (if under 18) Signature * Date *

In case of unforeseen circumstances (Stroke, Death, Terminally Ill, Etc.) these individuals are authorized on my behalf:

Name and Relationship * Phone # * Name and Relationship Phone #

Other Policies

Appointment Attendance: If you cannot attend a scheduled appointment, please notify the office within 24 hours prior to the appointment. Failure to do so may result in a $25.00 charge for your missed appointment and/or dismissal from our practice. * Prescriptions: Please notify us of any refills at least 3 business days before you run out. * Results: We will notify you of all results ordered by Dr. Betty Yao, MD (labs, ct, mri, etc.) * Billing Questions: Please contact your insurance company first to clarify why they are not paying on a claim, all other questions, you can call us M-F (9AM-12PM/ 1:30PM-3PM) * Return Check Fee: Per N.R.S 205.130 Issuing or passing a check, knowing that there is insufficient funds is a criminal offense. A $25.00 return check fee and any cost accrued for a returned check (certified mail, etc.) will be accessed to your account. *