Daoud Surgery and Family Medicine, PC

CONSENT AND PAYMENT AGREEMENT FOR TREATMENT VIA TELEHEALTH / TELEMEDICINE/ PHONE VISIT SERVICES

I, the undersigned, hereby give permission for my physician to conduct a telehealth visit either via video or phone call. I understand I may be billed for this service if my insurance doesn't cover it. This consent is good for any future visits as well that are done. I authorize the release of any information relating to all claims for benefits of myself/and or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for service rendered via video telehealth or phone visits or in office visits, without obtaining my signature on each claim to be submitted by myself and/or dependents. I will be bound by this signature as though the undersigned had personally signed the particular claim. I authorize my insurance to pay and hereby assign directly to Daoud Surgery and Family Medicine PC all benefits, if any, otherwise payable to me for his/her service as described on the attached forms. I understand I am financially responsible for all charges incurred that are not covered. I further acknowledge that any insurance benefits when received by and paid to Daoud Surgery & Family Medicine PC will be credited to my account, in accordance with the above said statement. I also agree to pay for any service rendered if I do not have insurance to Daoud Surgery & Family Medicine PC or the service is not covered by my insurance. My name typed in the first and last name boxes below indicate shall be legally binding as my signature that I agree with this payment for telehealth / telemedicine / video visits, phone visits and / or in person office visit.

Signature

First Name * Middle Name Last Name * Signature (if printing form to submit otherwise above First and Last Name counts as signature): Date of Birth: * Today's date *

INSURANCE INFORMATION

Please fill out the following if you do not have your current insurance information on file at the office. If you aren't sure if it is up to date, then please fill it out as well. The first section is about your primary insurance. The next section is about your secondary insurance if you have one. The third section is for you to add other insurance information as well. Thank you.

Primary Insurance Company Name Insurance Number/Enrollee ID: Issuer Number: Group Number: Subscriber's Name (if not you): Subscriber's Day of Birth (if not you): Date Issued: Subscriber's Social Security (if not you):

Secondary Insurance Information:

Secondary Insurance Company Name: Insurance Number/Enrollee ID: Issuer Number: Group Number: Subscriber's Name (if not you): Subscriber's Day of Birth (if not you): Subscriber's Social Security (if not you): Date Issued Other Insurance Information: