Authorization and Release
With my signature below, I voluntarily consent to the administration and cost of medical and surgical procedures for myself or my dependent. I also authorize payment directly to Walk in Medical Urgent Care, PC (d/b/a Urgent Care of NY and Urgent Care of Westchester), for all benefits otherwise payable to me. I understand that I am financially responsible and agree to pay all charges that are not paid by or billed to insurance or any other their party payer. I understand that I must pay in full today for all services rendered unless my insurance is accepted. I also understand that if insurance is accepted, I am responsible to pay all applicable insurance copays, coinsurance, and deductibles at time of service. If you are unable to verify my insurance at time of service, I will pay in full for services rendered.
I authorize Walk in Medical Urgent Care, PC, to release (verbal and written) confidential medical information to any person or entity, including my insurance carrier or employer, if treatment is related to employment or health care operations which may be liable to me or my practitioner(s) for charges related to treatment and for quality management, utilization review, transfer and follow-up purposes.