By not completing the insurance section, you understand that you will be a self pay patient. Please call the office for a Good Faith Estimate at 802-864-0192.
If you do not have insurance, please write "none" in the required fields below, thank you.
By signing this form, I consent to treatment which may include examinations, diagnostic tests, procedures, and/or other therapies to effectively diagnose and treat my medical conditions. I agree to assign payable benefits from my insurance and/or third-party payor directly to FSD. I authorize the release of medical records as required by my insurance carrier. I understand that I am responsible for all charges for which my insurance declines to pay. I am also providing consent to be contacted via phone, US Mail, e-mail, or text message until I revoke these permissions.