Main Street Medical Services, PLLC

Patient Form – 1

Male Female

My signature below acknowledges the following:

  • I have received a copy/am aware of the Patient Bill of Rights; as required by law and have had an opportunity to receive assistance in understanding and exercising these rights.
  • I have received a copy/am aware of this office's Notice of Privacy Practices, including the Private Health Information (PHI) designated at the time of visit.
  • I have received information on/am aware of the Speak Up Program Campaign.
Assignment of Benefits

I hereby assign all medical and/or surgical benefits, to include major benefits to which I am entitled, private insurance and any other health plan to Main Street Medical Services, PLLC.

This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered valid as original. I understand that I am financially responsible for all charged whether or not paid by said insurance. I hereby authorize said assignee to release all information to secure payment.

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