Patient Service Agreement & Consent
Lower Manhattan Medical Care, P.C. (“Provider”) is proud to provide you with personalized support and care. Please read and sign the following agreement; it lists our billing, scheduling and cancellation policies and procedures. If you have any questions, please ask.
A. Scheduling Services. If you schedule an appointment or communicate with Provider via online request form or via email, you are consenting for Provider to respond via email, even if you have not completed the email and text consent you will receive in conjunction with this Agreement.
B. Consent for Assignment of Insurance Benefits: I authorize the payment of insurance benefits payable directly to Provider.
C. Cancellation Policy. You understand that your appointment must be canceled at least twenty-four (24) hours in advance or you will be responsible for a $50 cancellation fee.
D. Confidentiality and Compliance. Provider will take appropriate precautions to keep your health information confidential and to not disclose it without your consent. You are also protected under the provisions of the federal Health Insurance Portability and Accountability Act (HIPAA) and any other applicable federal and state laws related to protection of patient information. I understand that my signature on this form gives Provider the authority to use and/or release my protected health information (PHI) in compliance with the Notice of Privacy Practices, which including using and releasing PHI for treatment, payment and health care operations