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Authorization of Treatment and Assignment of Benefits

I hereby authorize Carter J. Moore, MD, and the MP Weight Loss Staff to consent for treatment as he deems necessary.

Notice of Privacy Practice Patient Acknowledgement

I have received and/or reviewed this practice's Notice of Privacy Practices. The notices provide details about uses and disclosures of my protected health information that may be needed by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, the practice. I understand that I may obtain this practice's current Notice of Privacy Practices upon request.

Collection Policy

I understand that all charges incurred become my responsibility. Though an insurance claim may be filed, as a convenience to me, I understand that any applicable co-pays, deductibles, or co-insurance amounts are due on the same day services are rendered. *We accept all major credit and debit cards. (Insurance will only be billed for any lab work.)