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Thank you for choosing Next Level Urgent Care. Our main concern is that you receive high quality care. In order to prevent any misunderstanding and to serve you better, we ask that all patients read and understand our policies. If you have any questions or concerns, please do not hesitate to ask. I do hereby agree and give my consent for NEXT LEVEL URGENT CARE to furnish medical care and treatment the the listed patient considered necessary and proper in diagnosing or treating his/her physical condition. This may include information sent to other providers as necessary for follow-up or ongoing treatment. I hereby authorize and assign payment to NEXT LEVEL URGENT CARE of any type of reimbursement or payment from Medicare or State Medicaid programs or other third party payor, for any and all costs of my medical care provided at NEXT LEVEL URGENT CARE or by its agents, designees or independent contractors. Further, I understand that some ancillary providers may bill me separately and I assign my insurance benefits to them if their services are rendered during my treatment. I also authorize the release of my medical information needed by my insurance carrier to process any claims. The payment method used to pay my copay or co-insurance will be securely stored, and also used should any amount still be owed after my carrier processes the claim. Any amount due is determined by my insurance carrier. If requested, I will be provided with an itemized statement for services provided today. I will also be notified two days before any remaining balance is charged. I agree that if my payment method declines, I will be responsible for the balance and all collection costs. I UNDERSTAND MY RESPONSIBILITY FOR THE PAYMENT OF MY ACCOUNT. I authorize NEXT LEVEL URGENT CARE to release any medical or financial information to a medical care provider who is performing medical care of a diagnostic test on behalf of; or at the request of the health care provider of NEXT LEVEL URGENT CARE. I authorize NEXT LEVEL URGENT CARE, its agencies and designees, to utilize any information in my medical record for quality assurance and risk management activities. BY STATE LAW, you must be advised that the information authorized for release may include records which may indicate the presence of a communicable or venereal disease, which includes, but is not limited to diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Symptoms (AIDS). I hereby authorize NEXT LEVEL URGENT CARE to release medical information obtained in the course of my evaluation and treatment to my employer and/or employer’s representative (only in the case of job related injury/illness), my primary care physician and my insurance carrier.