Patient Information Form

Single Married Partnered Divorced Widowed

Male Female Transgender Other

Assignment of Benefits and Release of Information-Financial Agreement:
I hereby give lifetime authorization for payment of insurance benefits be made directly to Marla Kushner, DO and any assisting physicians or services rendered, I understand that I am financially responsible for all changes whether or not they are covered by insurance. In the event or default, I agree to pay all costs of collection, and any reasonable attornet's fees. I hereby authorize the healthcare provider to release all information necessary to secure the payment of benefits and also authorize the release of any confidential patient information to assist in treatment. I further agree that a photocopy of this agreement shall be valid as the original.


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Office Hours

9:00 am - 5:00 pm
9:00 am - 5:00 pm
9:00 am - 5:00 pm
9:00 am - 5:00 pm
9:00 am - 5:00 pm
9:00 am - 12:00 pm 1 - 2 per month