Patient Intake Form

I understand and agree that:

Synergy Medical Group may bill my insurance for covered services.

I authorize the release of information necessary to process claims and authorize payment of benefits directly to the practice.

I am financially responsible for all charges not covered by my insurance plan, including copayments, deductibles, coinsurance, non-covered services, and services denied by insurance.

Insurance verification or authorization does not guarantee payment.

I am responsible for providing accurate and up-to-date insurance information.

I agree to pay any outstanding balances in a timely manner.

Unpaid balances may result in late fees, collection efforts, or restrictions on scheduling future appointments.

I understand that Synergy Medical Group charges a $50 fee for any appointment that is not canceled at least 24 hours in advance, and I agree to be responsible for this fee.

I understand that laboratory testing, imaging studies, pathology services, durable medical equipment, prescriptions, and other services performed by third-party facilities are billed independently from Synergy Medical Group.

I am responsible for all charges from outside providers, even if the services were ordered by my Synergy Medical Group provider.

I understand that:

Third-party vendors set their own pricing.

These charges may apply toward my deductible or coinsurance.

Questions regarding these charges must be directed to the vendor or insurance carrier.

I agree to ask Synergy Medical Group if I have concerns about cost or alternative options.

I acknowledge that Synergy Medical Group maintains policies regarding scheduling, cancellations, no-show appointments, and late arrivals. I agree to follow these policies and understand that failure to comply may result in fees or limitations on scheduling future appointments.

I understand that Synergy Medical Group is not an emergency medical service. If I experience a medical emergency, I must call 911 or go to the nearest emergency facility.

I agree to respect the practice’s guidelines for professional behavior, appointment preparation, and timely communication related to my care.

Synergy Medical Group is committed to protecting your personal health information. This message serves as your Notice of Privacy Practices acknowledgment.

By receiving care from Synergy Medical Group, you acknowledge that:

You have been provided access to Synergy Medical Group’s Notice of Privacy Practices, which explains how your health information may be used or disclosed as permitted by law.

You understand that you may request a printed or electronic copy of the full Notice at any time.

You understand your HIPAA rights, including the right to access your records, request corrections, request restrictions, request confidential communication, and receive an accounting of disclosures.