Patient Information






In Case of Emergency




I hereby authorize Desert Kidney Associates to release all my insurance carriers or their representatives, any information, including the diagnosis and the records of any treatment or examination rendered to me during the period of such medical or surgical care. I authorize my doctor or his representative to act as my agent on helping me obtain payment from my insurance carriers.
I also authorize and request your company to pay directly to the above named clinic the amount due me in my pending claim for medical, major medical or surgical treatment or services by reason of such treatment of services rendered to:



I understand that if my Desert Kidney Associates financial account needs collection, all collection fees will be added to the original balance, including an annual interest charge of 10%.