Complete New Patient Packet

Michael E. Buxbaum, D.O., P.A. ("Buxbaum Medical") is required by law to maintain the privacy of your protected health information (PHI) and to provide you with notice of our legal duties and privacy practices.

• We may use and disclose your PHI for treatment, payment, and healthcare operations.
• You may request restrictions on certain uses and disclosures of your PHI.
• You may revoke any authorization you provide, in writing, at any time.
• We reserve the right to change our privacy practices for all PHI we maintain.
• You may file a complaint with our Privacy Officer or the U.S. Department of Health and Human Services if you believe your privacy rights have been violated.

It is the policy of Michael E. Buxbaum, D.O., P.A. to bill your insurance carrier as a courtesy. If your insurance carrier does not remit payment within 60 days, the balance will be due in full from you. Payment of your estimated share is due at the time of service.

I hereby assign all medical and surgical benefits to Michael E. Buxbaum, D.O., P.A. and authorize my insurance carrier(s) — including Medicare, private insurance, and any other health/medical plan — to issue payment directly to the practice. I authorize release of any information necessary to insurance carriers and the use of a photocopy of my signature to process insurance claims. I understand I am responsible for any amount not covered by insurance, including collection costs and attorney fees upon default.