Name

Email

Mailing Address

Birthday & Phone Numbers

Please include the area code for all phone numbers

Person to contact in case of emergency:

To better server our patients, we will automatically fax all prescriptions to the pharmacy for you:

Authorization & Financial Policy

I, the undersigned certify that I (or my dependent) understand that Richard Kim Medicine, is a Direct Pay Practice and agree to sign the Opt Out Contract and accept full financial responsibility for services performed by Richard Kim, M.D.

I understand that Richard Kim, M.D. has the right to charge me $35 for any returned check.

CANCELLATION FEE POLICY- My signature below shows that I understand the cancellation policy: $95 Fee for less than 24 hours notice of cancellation for consult and follow up office visits or not showing for the appointment. $200 Fee for less than 7 days notice for scheduled procedures or not showing for the appointment. I also understand that payment of these fees must be made prior to any future appointments being scheduled.

I, the undersigned, certify that I (or my dependent) understand that All Stem Cell and PRP deposits are non-refundable.

For HIPAA Compliance, please answer the following questions:

I authorize you to leave appointment messages or send information to me via:

My signature below also indicates that I have been provided Richard Kim Medicine Notice of Privacy Practices.

My signature below authorizes Richard Kim, M.D. general consent for evaluation, treatment and the understanding of Richard Kim Medicine Financial and Cancellation Policy

Signed: (Patient or person authorized to consent signature)

I give Richard Kim M.D., permission to release medical information to the above referring and/or Primary Care Physician.

Submit

We gladly accept Cash, Checks, MC, VISA, AMEX, DISCOVER. We also offer CARE CREDIT.