Test Form

HIPAA requires that written authorization be obtained before healthcare providers or staff may release your individually identifiable information to a third party (e.g., spouse, family member, and/or friend closely associated with you). This release will enable our staff to protect your individual identifiable information and control to whom this information is released. If desired, please list up to three individuals whom you would authorize to have access to your information.

I hereby give authorization for payment of insurance benefits to be made directly to Darshan K. Kapadia, M.D., P.A. or Neha Dhudshia, M.D., P.A. and any assisting physicians or PAs, for services rendered. I understand that I am financially responsible for all charges not covered by my insurance company. In the event of default, I agree to pay all costs of collection, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits, and further agree that a photocopy of this agreement shall be valid as original. I verify the above information is correct.

I authorize Darshan Kapadia, MD and/or Neha Dhudshia, MD to process the credit card on file for services rendered as outlined in the Office Financial Policy. It is my responsibility to notify the office of any future changes to the credit card on file.