+ 001 0231 123 32



All demo content is for sample purposes only, intended to represent a live site. Please use the RocketLauncher to install an equivalent of the demo, all images will be replaced with sample images.

Authorizations and Consents

HIPAA Use and Disclosure Authorization

I hereby authorize Circle of Life Family Medicine to disclose my protected health information t o the person named above. 

Notice of Privacy Practices

I have been given the opportunity to read a copy of Circle of Life Family Medicine's Notice of Privacy Practices (posted in office).  This Notice describes how Circle of Life Family Medicine may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.

Insurance and Payment Authorization

Should a dispute arise concerning injury related claims, or should this office not be able to verify coverage, the patient is ultimately responsible for payment, regardless of any claims pending.

I hereby authorize Circle of Life Family Medicine to furnish information to insurance carriers concerning my illness and treatments, and I hereby assign to Circle of Life Family Medicine all payments for medical services rendered to myself or my dependents.  I understand that I am responsible for any amount not covered by my insurance.

Laboratory Processing

Circle of Life Family Medicine has no way of knowing which laboratories are preferred by your insurance carrier.  Please choose from the options below which lab(s) you would like COLFM to send your specimens to.  If your insurance carrier does not cover this benefit in full, you will receive a bill from the lab directly, which is in no way related to COLFM billing and thus, you must contact the lab directly with any questions.

Injection Therapy

It is the responsibility of the patient to know the benefits of your health insurance plan.  If you are considering being treated with injection therapy, and have discussed this with one of our physicians, it is mandatory that you contact your health insurance carrier prior to starting your treatment to see if it is a covered service to have the injections administered in an office setting.  You will be given billing information from our office to give to the insurance company.  Any amount not covered by your insurance carrier will become your responsibility and you will be billed accordingly.

  Refresh Captcha