I certify that the information provided on this form is accurate and complete. I acknowledge receipt of {{ practice_name_consent }}'s Notice of Privacy Practices describing how my protected health information may be used and disclosed in accordance with HIPAA, and I consent to medical evaluation and treatment by the group's providers.

I authorize the release of medical information to my insurance carrier(s) for the purpose of processing claims, and I assign medical benefits to the practice. I understand I am financially responsible for charges not covered by my insurance.