I authorize Gwinnett Clinic and its physicians/nurse practitioners to examine, evaluate, and treat the patient listed above for current and all future problems for which the same patient returns for examination, evaluation, and treatment. I understand that payment, in full, is due at the time of service unless approved by office staff. I also authorize releasing my health information to my referring physician/clinic, employer (if workman's compensation injury), auto insurance company (if motor vehicle accident), and/or health insurance company.
I understand that, as a courtesy, Gwinnett Clinic may file my claims to the appropriate insurance company. However, although insurance claims will be submitted, all charges are primarily and ultimately my full responsibility. If my insurance payment is not received within 60 days from the date of service, I agree to pay the entire balance due, unless my insurance company has an overriding contractual agreement with Gwinnett Clinic and its physicians/nurse practitioners. I also agree to pay interest at the rate of 1.5% per month if my bill is not paid within 90 days from the date of service. Due to default, I also agree to pay all cost of collection, including but not limited to, court costs, collection agency charges, attorney fees, etc.