• Patient Information

  • Emergency Contact

  • Insurance Information

  • Additional Insurance

  • Insured / Spouse / Parent

  • I hereby authorize CULLMAN REGIONAL FAMILY CARE CLINIC to furnish to the insurance company(s) on file or to a designated attorney, all information which said insurance company(s) or attorney may request. I hereby assign to CULLMAN REGIONAL FAMILY CARE CLINIC all money to which I am entitled for medical and/or surgical expense relative to the service rendered by him, but not to exceed my indebtedness to said physician and/or surgeon. It is understood that any money received from insurance company(s) on file, over and above my indebtedness will be refunded to me when my bill is paid in full. I understand I am financially responsible to said doctor(s) for charges not covered by this assignment. I further agree in the event of non-payment, to bear the cost of collection, and/or court cost and responsible legal fees should this be required. I understand that it is my responsibility to furnish current and correct personal and insurance information to CULLMAN REGIONAL FAMILY CARE CLINIC in a timely manner.