*This information is taken in an effort for our practice to meet new healthcare requirements for compliance. You are entitled to review your health care record on line. If you have provided us with an email address an access code will be sent to you from our electronic health records (EHR) Practice Fusion.

INSURANCE AUTHORIZATION AND ASSIGNMENT FORM

I hereby authorize Br. Andrea Cunha to diagnose, treat and manage the medical condition(s) presented at the time of the visit and to furnish all information to the insurance carriers concerning my illness and treatments. I hereby assign all insurance payments to Dr. Andrea Cunha for the medical services rendered to my dependants or myself. I understand that I am responsible by any amount that is not a covered service under my insurance.

All professional services rendered are submitted directly to your insurance company for payment, as long as we participate with the insurance company. If we do not accept your insurance plan the necessary forms will be completed to help expedite insurance carrier payments. It is the patients responsibility to pay all fees, co-payments, deductibles and or co-insurance when services are rendered, unless other arrangements have been made in advance with our office, It is also the responsibility of the patients to secure the necessary referrals from his/her primary care physician.

I have been made aware of the Health Insurance Portability and Accountability Act (HIPPA) BIPAA which protects an individual's health information and his/her demographic information
ensuring the privacy and security of individual identifiable information. A copy of said policy has been presented to me for viewing.