Authorization For Service – Better Health Medical Associates

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Coral Harbour | P.O. Box SS-19341 | Nassau, Bahamas

(242) 376-7417

[email protected]

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Home
About Us
- Primary Physician
Services
Payment Policy
FAQ
Contact Us

NB: A VALID GOVERNMENT ISSUED PHOTO ID IS REQUIRED

Photo ID

Date:

Time of Arrival:

Providing Doctor:

Type of Visit

Sick Medical Health Certificate Annual/School Medical Family Planning Sick Gynae Results Industrial Accident Antenatal Injury

Other:

New Patient Returning Patient

Appointment?

No Yes

Payment Method-Self Pay or Insurance (Please provide your card)

Cash Credit Card Colina Bahama Health Atlantic Medical First Care BAF Financial NHI

Other:

CONSENT FOR TREATMENT:

We hereby authorize Better Health Medical Associates to administer medications and perform any diagnostic procedures that may be necessary or proper health care. I authorize Better Health Medical Associates to bill my private insurance.

Policy/NIB Card #:

Authorization #:

Patient's Name:

D.O.B: MONTH:

DAY:

YEAR:

Signature:

Tel (H)

Tel (W)

Tel (C)

Address:

Email

Sex

Male Female

Occupation:

Employer:

EMERGENCY CONTACTS

Name:

Tel:

Relationship:

Name:

Tel:

Relationship:

Name:

Tel:

Relationship:

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