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Patient Services Agreement

I authorize Kerzner Associates, P.C., to keep my credit card information securely on file. My credit card can be used for payment under the conditions I have initialed below

I have been given a copy of, read, and agree to the terms and conditions as stated in the Kerzner Associates Patient Services Information document. I have been offered/given a copy of our Policies and Practices To Protect the Privacy of Your Health Information. (“Massachusetts Notice Form”)


I understand and consent to Kerzner Associates submitting necessary information to my insurance company in order to either be reimbursed or to get authorization for treatment.  I have read and understand Kerzner Associates’ policy which states that services may be withheld if I have a past due balance, and that Kerzner Associates has a zero balance policy.


By signing below, I understand, agree to, and identify myself as the responsible party for all fees not covered by health insurance, as outlined in the Patient Services Information document.  If you are between the ages of 18 and 26 and are not the policyholder for your insurance coverage, your signature below authorizes us to communicate with the policyholder.


When you sign this page, it represents an agreement between you and Kerzner Associates. You may cancel this agreement at any time in writing. That cancellation will be binding on Kerzner Associates unless we have taken action in reliance on it; for example, if there are obligations imposed on your clinician by your health insurer in order to support claims made under your policy; or if you have not satisfied any financial obligation you have incurred.


By signing below, I agree to give my clinician at Kerzner Associates, P.C. permission to communicate with my Primary Care Physician for the sake of coordinating care.

By initialing, I authorize Kerzner Associates, P.C. to send a thank-you note to the person/ agency who referred me.  This would not include any clinical information.

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