![]() ![]() I authorize NEXT LEVEL URGENT CARE to release any medical or financial information to a medical care provider who is performing medical care of a diagnostic test on behalf of or at the request of the health care provider of NEXT LEVEL URGENT CARE. I UNDERSTAND MY RESPONSIBILITY FOR THE PAYMENT OF MY ACCOUNT. I agree that if my payment method declines, I will be responsible for the balance and all collection costs. ![]() ![]() I will also be notified two days before any remaining balance is charged. If requested, I will be provided with an itemized statement for services provided today. Any amount due is determined by my insurance carrier. The payment method used to pay my copay or co-insurance will be securely stored, and also used should any amount still be owed after my carrier processes the claim. I also authorize the release of my medical information needed by my insurance carrier to process any claims. Further, I understand that some ancillary providers may bill me separately and I assign my insurance benefits to them if their services are rendered during my treatment. I hereby authorize and assign payment to NEXT LEVEL URGENT CARE of any type of reimbursement or payment from Medicare or State Medicaid programs or other third party payor, for any and all costs of my medical care provided at NEXT LEVEL URGENT CARE or by its agents, designees or independent contractors. This may include information sent to other providers as necessary for follow-up or ongoing treatment. I do hereby agree and give my consent for NEXT LEVEL URGENT CARE to furnish medical care and treatment the the listed patient considered necessary and proper in diagnosing or treating his/her physical condition. If you have any questions or concerns, please do not hesitate to ask. In order to prevent any misunderstanding and to serve you better, we ask that all patients read and understand our policies. Our main concern is that you receive high quality care. Thank you for choosing Next Level Urgent Care. ![]()
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