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PATIENT INFORMATION Please Complete All Sections of this Form
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I have been informed and understand that Dr. Edwards and the staff of Bio Health Center practice Homeopathic, Nutritional, Orthromolecular, Neural Therapeutic, Herbal, Neuro-Integrative and Preventive Medicine under licensing authority of the Nevada Board of Homeopathic Medical Examiners. I understand that the determination as to whether any and all medical/health services provided are "covered" by my private insurance/health plan will be made after these services have been provided. I understand that I am fully responsible for payment for any and all medical/health services provided by Edwards/Malik and I will attest in writing to this at each visit. I understand that payment is due at the time of service unless specific arrangements were made in advance and that credit can be obtained by using Mastercard™ or Visa™. I understand that any outstanding balance owed will be subject to a 1.5% monthly interest charge.
NOTICE TO ALL MEDICARE™ PATIENTS - ACKNOWLEDGMENT
I have been informed that MEDICARE™ does NOT COVER ANY SERVICES provided by Edwards/Malik, including medical acupuncture, homotoxicology, nutritional therapy, electro-acupuncture, chelation therapy, neural therapy, bio-oxidative therapy, and/or preventive medicine. Although I will not be reimbursed for the above medical services, I agree to said services and agree to pay for these services. I understand payment is due at the time of service unless specific arrangements were made in advance, that credit can be obtained by using Mastercard™ or Visa™ and that any outstanding balance owed will be subject to a 1.5% monthly interest charge.
FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) AND GENERAL AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION - ACKNOWLEDGMENT: David A. Edwards, MD, HMD, LTD does NOT transmit ANY health care claims information electronically. Therefore, we do NOT "qualify" as a "covered entity" under the provisions of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA or PL104-191). However, we do agree with protecting the absolute privacy of ALL personal-private health information in our custody, and we do fulfill ALL mandated federal requirements of HIPAA in our handling and care of ALL personal-private health information. An outline of HIPAA mandates is provided on the reverse side of this form. I authorize the release of any and all medical information to my insurance/health plan administrator, any and all physician(s) I may be referred to and/or any person(s) legally designated by me.
I have read, understand and acknowledge ALL of the above:
Signature (Patient/Guardian if minor)
Date: 
