DOYLESTOWN THYROID AND ENDOCRINE ASSOCIATES

Patient Demographics Electronic Form

I hereby authorize Doylestown Thyroid & Endocrine Associates to release any information necessary to insurance carriers to process claims. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance remaining after submission to my insurance. I have received and reviewed the practice’s Financial Policies and Procedures

By submitting this form, I am acknowledging that Doylestown Thyroid and Endocrine Associates provided to me information about its Notice of Privacy Practices. This notice provides information about how we may use and disclose your protected health information. I have received and reviewed this practice’s Notice of Privacy Practices.