NO FEE Covid-19 Testing

Medicare

Below please add your Medicare Information.

Informed Consent For Procedure

I hereby consent to the performance of medical procedure, including diagnostic x-rays and various forms of physical therapy, diagnostic testing, on me (or on the patient named below, for whom I am legally responsible) by a doctor, NP, RN, Or Medical assistant and or other licensed doctors who now or in the future treat me while employed by, working or associated with or serve as back up for the doctor(s) employed by Cunico Health and Wellness, including those working at the clinic or office listed below or any other office or clinic. I have had an opportunity to discuss with the doctor named below and/or with other office or clinic personnel the nature and purpose of procedures. I understand and am informed that, in the practice of medicine, there are some risks to treatment including, but not limited to sprains, fractures, strokes, disc injuries, and dislocations. I do not expect the doctor to be able to anticipate all the risks and complications, judgment during the course of the procedure which the doctor feels at the time, based upon the facts they know, and is in my best interest. I have read or have had read to me, the above consent. I have also had the opportunity to ask questions about its consent, and by signing below I agree to the above-mentioned procedures. I intend this consent from to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment.

Agreement to Bring Payment If patient paid directly from the Carrier

As a courtesy to our patients, Cunico Health and Wellness will submit insurance claims on your behalf. In some cases, the insurance carrier will make payment directly to the patient. If this is the case, once payment has been made to you or an EOB has been issued by the insurance carrier, we require that you bring such payment along with the entire EOB to Cunico Health and Wellness’ office. If we do not receive payment once you have been paid, you will be responsible to pay the entire open balance in full. By signing below, you agree to bring all checks/Explanation of Benefits to our office.