Name *

Please list the name listed on your insurance card

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I consent and agree that: In the event that I have a copay or did not meet my deductible, I will provide a credit card below. I will Include card number, cvv, exp. I consent and agree that all copays will be automatically charged at time of visit. All unmet deductibles will be billed via mail. *

Please note a 3% processing fee will be charged for all credit card payments. To avoid this fee you can pay via quick pay (reach out to the office for details). For any questions regarding insurance and/or deductible status please email billing@bleugloveconcierge.com.

I consent and agree

I consent and agree

By checking the box below, I consent to the Office of Adina Gelfand Erez PA-C (Bleu Glove Concierge) the rights to release my medical records and test results to an insurance company, third-party payer, or their agents for the purpose of determining eligibility, benefits, and obtaining payment for services provided to me. I also understand that I am responsible for any remaining balance not covered by insurance, governmental agencies, or third-party payers. Additionally, I acknowledge that the medical director for this practice is Dr. William Lum, MD, and that all insurance claims will be processed through Forest Urgent Care. *

I consent and agree

I consent and agree

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

By signing below, I acknowledge that I am responsible for the full cost of my visit if I do not have insurance, if my insurance is not accepted by this office, or if I am seen for a visit that is not covered under the office's insurance processing policies as stated by the office. I understand that payment will be required at the time of service, and I agree to pay for all charges. I also understand that I am financially responsible for ensuring any necessary insurance information is provided to the office prior to my visit for lab or imaging center processing. *

I consent and agree

I consent and agree