Patient Paperwork

I authorize Dr. Pearson to release my information in my record to any medical practitioner, physician, hospital, medical institution or facility to which I may be referred to assist in my care.

I authorize Dr. Pearson to obtain any information any medical practitioner, physician, hospital, medical institution or facility to which I may be referred to assist in my care.

PPO / HMO Patients Financial Responsibility

I understand that I am insured through an HMO /PPO Ian. I understand that it is my responsibility to obtain the proper and necessary referrals from my primary care physician before seeing Dr. Pearson.

Although Dr. Pearson and his staff will make all reasonable efforts to assure that ordered testing is covered by my medical plan, I also understand that it is ultimately my responsibility to do so before having any testing or treatment.

I understand that I am fully and totally responsible for any fees rejected by my insurance carrier. I shall also be responsible for any appeals of such rejected claims.

I further agree to inform Dr. Pearson's office of any changes in my insurance coverage for carrier in a timely fashion.

I give permission for Dr. Pearson or his staff to leave a message on voicemail.