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Consent for Services and Disclosure of Protected Health Information

Last Updated 9/15/2022

I hearby consent to medical evaluations, testing and/or treatment provided to me by the staff of Midwest Express Clinic. I also understand that Midwest Express Clinic may use or disclose any Protected Health Information (PHI) necessary to carry out treatment, payment or healthcare operations. I authorize release of any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits, otherwise payable to me, to be paid directly to Midwest Express Clinic and I agree to pay any remaining balance once my insurance plan has processed my claim. I understand that I am responsible for any balance remaining due within 30 days of the first billing date. Any Balance remaining after the 30 days will be considered past due. Should my account go more than 30 days past due, I agree to pay interest at the rate of 18% per annum (1.5% monthly) on the balance due. Furthermore, in the event that my balance becomes past due Midwest Express Clinics have the right to refer any unpaid balance on my account to an attorney for collections and that in addition to any unpaid balance, I may be held responsible for the costs of collection including, but not limited to, court costs and attorney’s fees.

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