Consent Forms
Financial Policy - When signed by the patient, this serves as confirmation that the patient has read and understood their financial requirements and responsibilities as well as the responsibilities of the insurance company and of Kidney Associates for services rendered.
Privacy Consent - Each patient consent section should be carefully read and signed to give authorization for medical services rendered and to comply with HIPAA regulations.
Indemnity Form: Here is an insurance form. If you have indemnity insurance, please read and sign.
Medicare: Here is the Medicare Form - Please read, review and sign if you have Medicare.
Managed Care: If you are in a managed care plan, please read and sign this form.
Cash Pay: If you are paying cash for your care, please read, review and sign this form.
Consent Form: Each patient consent section should be carefully read and signed to give authorization for medical services rendered and to comply with HIPAA regulation. Please download, read and complete. Then fax to (713)795-4627 This form acknowledges that you read the HIPAA agreement and consent to treatment
