Patient Registration

Basic Information
Primary Insurance
Assignment and Release
I certify that I, and/or my dependent(s), have insurance coverage with:
I assign directly to Lauren Fox, FNP, BC, CCH all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named care provider may use my health care information, and may disclose such information to the above-named Insurance Company and their agents for the purpose of obtaining payment for services and determining insurance benefits, or the benefits payable for related services. This consent will end when my current treatment plan is completed, or one year from the date signed below.