Notice of Privacy Practices

Your name and signature below indicate that you have received / been offered a copy of Burton Urgent Care's Notice of Privacy Practices on the date and time indicated. If you have any questions regarding the information in Burton Urgent Care's Notice of Privacy Practices, contact the Burton Urgent Care Office at 810-820-8706

Name*

Medical Care/Treatment Financial Policy

You will be responsible for either full payment or payment as indicated by your insurance plan unless you are here for employer paid services. All payments are due before service.

If you have insurance... If Burton Urgent Care has a contract with your insurance company we will file today's charges with that insurance company. You will be responsible today for your co-payment , coinsurance and/or deductible, and the cost of any services not covered by insurance. +++ You may receive a bill from Burton Urgent Care for an unpaid balance.

If you do not have insurance... If you do not have insurance coverage or Burton Urgent Care does not have a direct contract with your insurance company, you will be required to pay in full for your visit today. You can expect to pay an initial payment for medical care/treatment based on posted pricing, which will be collected at check-in. +++ If your treatment requires more complex evaluations, lab tests, vaccines, medications, X-rays, or supplies, you will be charged for those in addition to the appropriate office visit fee. These fees will be collected after service and treatment has been provided.

Release of Medical Records, Assignment of Benefits, Financial Responsibility

I authorize Burton Urgent Care to submit claims to my insurance carrier as well as medical records needed to evaluate these claims for payment. I understand that if my employer is responsible for paying all or part of this claim, they will receive the medical information needed to pay this claim and I authorize release of this information. I further authorize payment of benefits, otherwise payable to me, to be made payable to Burton Urgent Care. I understand that I am financially responsible for all charges not covered by my insurance. I authorize Burton Urgent Care to release my medical records to my primary care physician unless I choose to decline.

If my insurance company is not in Burton Urgent Care's network or I have no insurance coverage, I understand that I am financially responsible for all charges and must make full payment today.

Consent For Medical Treatment

I give permission to Burton Urgent Care to perform the medical and surgical processes, treatment, and/or procedures that the physician and other non-physician providers and assistants may deem to be necessary. In addition I authorize Burton Urgent Care to release any information obtained during the course of my examination and/or treatment to my health care insurer or other payer.