PRIMARY

Acknowledgement of Receipt of Privacy Notice
By signing below, I hereby acknowledge that I am aware of the Privacy Practices that Affiliated Troy Dermatologists has in place. I can request a copy of this privacy agreement for my records at any time.

I have read and understand the above and allow Affiliated Troy Dermatologists to give personal information to the above listed persons.

As the patient or parent/guardian of the patient, I agree to the following:

• The use of this form on all insurance submissions.
• The release of information to my/the patient’s insurance companies.
• The responsibility for my/the patient’s bill.
• The doctor may act as my/the patient’s agent in helping to obtain payment from the insurance companies.
• A copy of this authorization to be used in place of the original.
• The doctor may file a complaint to the insurance commissioner on my behalf.
• The doctor may notify the insurance companies, when their policy prohibits payment to the physician directly, to mail the checks made out to me to their office address.
• Regardless of the divorce decree whoever brings in the minor is responsible for payment.
  I have read and understand all of the above statements and agree with their provisions.