Waiver of Liability 

               

  FARZIN SEHATI, MD | RAFAEL YAAKOBOV, FNP

64-05 Yellowstone Blvd, CF 104, Forest Hills, NY 11375. Tel: 718-885-4257; Fax: 718-885-4261.


Please fill in all the information as accurately as possible. All answers are confidential.

I/We hereby agree as follows:

1. Assignment: In consideration of hospital and or physician services which have been or will be provided to the above-named patient, I hereby assign to Future Care Internal Medicine (provider) all the medical insurance benefits which may become available by reason of the medical treatment of the patient including any insurance policies and other third-party payers to pay over to the practice any sums due for physician’s services.

2. Agreement to pay: I agree to pay for all practice services rendered for and on behalf of the patient, and understand that to the extent permitted by law, where insurance or other third party benefits are insufficient to pay for all of the patients’ physician’s services rendered, that I will be responsible for the payment of any balances due as determined by the respective provider of service.

3. Attorney’s fees: If there is a default in the payment of any sums due, I agree that if the practice retains an attorney, not a salaried employee to prosecute a claim for unpaid balances, that in such event I will additionally pay reasonable attorney’s fees and court costs.

4. Release of information: I hereby grant permission to the provider to release my medical information to the patient’s insurance company and other third-party payers, including Medicare and Medicaid, which may be required to determine the benefits due to the patient or physician(s).  I understand that such disclosures are confidential, and where applicable are protected by Federal Confidentiality Regulations (42 CFR Part 2).  I understand that my representative and I may revoke this consent at any time with written notice.
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