By submiting the Registration Form you agree to the following:

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly

to the physician.

I understand that I am financially responsible for any balance. I also authorize Z Medical Care or insurance company to release any information required to process my claims.

https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html

I have received and read the HIPPA Privacy Notice and I am aware of my rights as a patient. I make the following special request for confidential communication.

 

If you have any question/Comment Please let us know!

Your Details

Let us know how to get back to you.


How can we help?

Feel free to ask a question or simply leave a comment.