I hereby consent to and authorize any medical treatment as deemed necessary by Palm Glades Rural Health Associates.
Unless advance arrangements are made, payment of services is expected at the time they are rendered. As the patient/parent, you are responsible for any charges incurred. Medicaid patients must be eligible at the time of service. We accept assignment of Medicare and require 20% coinsurance after the deductible has been met
We request a signature on the attached form for authorization and release.
In the event that the insurance company fails to respond within 90 days or denies your claim, you will be responsible for any charges.