Pharmacy of Choice:

Patient Information:

Billing Information:

Telephone Disclosure:

Please mark if applicable:

Insurance Information:

I understand I am required to provide a copy of my Medical Insurance card and proof of coverage within my insurance plans time frame or I will be responsible for the full charges of my appointments.

Family Income:

Please note: Agencies that provide funding to Georgia Highlands Medical Services (GHMS) require that we obtain the information below. It is through funding from these agencies that GHMS is able to deliver cost-effective, meaningful care to our patients. Information you provide here will not be shared with any other agency.

Family members registered at GHMS:

Payment and medical treatment consent

Consent for Treatment: I hereby consent to any treatments, diagnostic tests or studies necessary by any provider or clinical staff member of Georgia Highlands Medical Services. I also authorize the Physician, Nurse Practitioner, Physician Assistant, Certified Nurse Midwife or Licensed Clinical Social Worker to give me/my dependent reasonable and proper medical care by today’s standards. Georgia Highlands Medical Services is an entity that participates in Title X Services. I also authorize the release of any medical information, including information related to psychiatric care, drug and alcohol abuse, and HIV/Aids confidential information required in the processing of an insurance claim, or any medical information that is needed for utilization review or quality assurance activities. I hereby authorize my insurance or Medicare benefits are paid directly to Georgia Highlands Medical Services. I also understand that any portion that is not covered by Insurance is my responsibility to pay. Payment is expected at time of service and Georgia Highlands Medical Services may use any means deemed necessary to collect a debt. A photocopy of this authorization shall be considered as effective and valid as the original. All above information is correct, and this will remain in effect until revoked by me in writing.