Health History Form

I understand that the information I have given is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in the patient's medical status.

I hereby authorize the release of any information pertaining to the patient's medical treatment necessary to process any insurance claims. I further authorize the application of insurance benefits toward any covered services on my behalf; I authorize payment of these benefits to the office. I understand that I am responsible for any amount not covered by insurance.