New Patient Registration Form

I authorize the release of any information including the diagnosis and the records of any treatments or examination rendered to me or my child during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to the doctor or doctor's group insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I hereby give the practice my consent to check my external prescription history. I authorize WMFH physicians to treat me or my minor child. ** WMFH complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.