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Home
For Patients
Patient Registration
Make Payment
Contact
For Health Care Providers
Register as a Healthcare provider
Provider documentation
Services
Home
For Patients
Patient Registration
Make Payment
Contact
For Health Care Providers
Register as a Healthcare provider
Provider documentation
Services
X
Contact Number
832-730-4479
Home
For Patients
Patient Registration
Make Payment
Contact
For Health Care Providers
Register as a Healthcare provider
Provider documentation
Services
X
Patient Registration
Name
(Required)
First
Middle
Last
Today’s Date
(Required)
MM slash DD slash YYYY
Email
Phone
Address
(Required)
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Date of Birth (MM/DD/YYYY)
(Required)
MM slash DD slash YYYY
Sex Assigned at Birth
(Required)
Marital Status
(Required)
Single
Married
Divorced
Widowed
Separated
Other Information
Name of Client’s Employer
Work Phone
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Spouse Name
Spouse Work/Cell Phone
Insurance Information
This field is hidden when viewing the form
Is this visit related to an accident?
(Required)
No
Yes
This field is hidden when viewing the form
please specify if AUTO or Other
This field is hidden when viewing the form
Is this visit related to a work-related accident?
(Required)
No
Yes
This field is hidden when viewing the form
please provide Workman’s Comp Ins.
This field is hidden when viewing the form
Primary Insurance
(Required)
This field is hidden when viewing the form
Policy Holder Name
(Required)
This field is hidden when viewing the form
Policy Holder’s Employer
(Required)
This field is hidden when viewing the form
Policy Holder’s SSN
(Required)
This field is hidden when viewing the form
Group#
(Required)
This field is hidden when viewing the form
Policy ID#
(Required)
This field is hidden when viewing the form
Policy Holder’s DOB
(Required)
MM slash DD slash YYYY
This field is hidden when viewing the form
Client’s Relationship to Policy Holder
Self
Spouse
Other
This field is hidden when viewing the form
Other
This field is hidden when viewing the form
Secondary Insurance
This field is hidden when viewing the form
Policy Holder Name
This field is hidden when viewing the form
Policy Holder’s Employer
This field is hidden when viewing the form
Policy Holder’s SSN
This field is hidden when viewing the form
Group#
This field is hidden when viewing the form
Policy ID#
This field is hidden when viewing the form
Policy Holder’s DOB
MM slash DD slash YYYY
This field is hidden when viewing the form
Client’s Relationship to Policy Holder
Self
Spouse
Other
This field is hidden when viewing the form
Other
Financial Obligation.
I agree that I am financially responsible for payment of all amounts due for services provided by Obur Health, P.A. and/or its employees or independent contractors. I understand that I am responsible for paying for services regardless of whether I have insurance coverage or if other parties are also responsible for my care. I will not be responsible for payment if my financial obligation is waived due to contractual agreements between Obur Health, P.A. and my insurer, or if prohibited by law. In the event of collection, I agree that the costs of collection, including attorney’s fees and court costs, will be added to my financial obligation to Obur Health, P.A.. This agreement is governed by Texas law, and I agree that venue and agree will be in Greene County, Texas.
Certification.
I certify that I have read all parts of this Authorization, Financial Obligation, and the Consent for Services. I accept all the terms and conditions, confirm that all representations I have made are true, and agree that a copy of this form is as valid as the original. This form is effective for one year unless I revoke it in writing.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Relationship to Client
(Required)
(if signed by a parent, legal guardian, or representative)
Non-Insured Patient Payment Form
Patient Registration
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Today’s Date
(Required)
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Enter Amount
(Required)
Credit Card
(Required)
Name
(Required)
First
Middle
Last
Today’s Date
(Required)
MM slash DD slash YYYY
Email
Phone
Address
(Required)
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Date of Birth (MM/DD/YYYY)
(Required)
MM slash DD slash YYYY
Sex Assigned at Birth
(Required)
Marital Status
(Required)
Single
Married
Divorced
Widowed
Separated
Other Information
Name of Client’s Employer
Work Phone
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Spouse Name
Spouse Work/Cell Phone
Insurance Information
This field is hidden when viewing the form
Is this visit related to an accident?
(Required)
No
Yes
This field is hidden when viewing the form
please specify if AUTO or Other
This field is hidden when viewing the form
Is this visit related to a work-related accident?
(Required)
No
Yes
This field is hidden when viewing the form
please provide Workman’s Comp Ins.
This field is hidden when viewing the form
Primary Insurance
(Required)
This field is hidden when viewing the form
Policy Holder Name
(Required)
This field is hidden when viewing the form
Policy Holder’s Employer
(Required)
This field is hidden when viewing the form
Policy Holder’s SSN
(Required)
This field is hidden when viewing the form
Group#
(Required)
This field is hidden when viewing the form
Policy ID#
(Required)
This field is hidden when viewing the form
Policy Holder’s DOB
(Required)
MM slash DD slash YYYY
This field is hidden when viewing the form
Client’s Relationship to Policy Holder
Self
Spouse
Other
This field is hidden when viewing the form
Other
This field is hidden when viewing the form
Secondary Insurance
This field is hidden when viewing the form
Policy Holder Name
This field is hidden when viewing the form
Policy Holder’s Employer
This field is hidden when viewing the form
Policy Holder’s SSN
This field is hidden when viewing the form
Group#
This field is hidden when viewing the form
Policy ID#
This field is hidden when viewing the form
Policy Holder’s DOB
MM slash DD slash YYYY
This field is hidden when viewing the form
Client’s Relationship to Policy Holder
Self
Spouse
Other
This field is hidden when viewing the form
Other
Financial Obligation.
I agree that I am financially responsible for payment of all amounts due for services provided by Obur Health, P.A. and/or its employees or independent contractors. I understand that I am responsible for paying for services regardless of whether I have insurance coverage or if other parties are also responsible for my care. I will not be responsible for payment if my financial obligation is waived due to contractual agreements between Obur Health, P.A. and my insurer, or if prohibited by law. In the event of collection, I agree that the costs of collection, including attorney’s fees and court costs, will be added to my financial obligation to Obur Health, P.A.. This agreement is governed by Texas law, and I agree that venue and agree will be in Greene County, Texas.
Certification.
I certify that I have read all parts of this Authorization, Financial Obligation, and the Consent for Services. I accept all the terms and conditions, confirm that all representations I have made are true, and agree that a copy of this form is as valid as the original. This form is effective for one year unless I revoke it in writing.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Relationship to Client
(Required)
(if signed by a parent, legal guardian, or representative)
Non-Insured Patient Payment Form
Patient Registration
Non-Insured Patient Payment Form
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Today’s Date
(Required)
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Enter Amount
(Required)
Credit Card
(Required)
Patient Registration
Name
(Required)
First
Middle
Last
Today’s Date
(Required)
MM slash DD slash YYYY
Email
Phone
Address
(Required)
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Date of Birth (MM/DD/YYYY)
(Required)
MM slash DD slash YYYY
Sex Assigned at Birth
(Required)
Marital Status
(Required)
Single
Married
Divorced
Widowed
Separated
Other Information
Name of Client’s Employer
Work Phone
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Spouse Name
Spouse Work/Cell Phone
Insurance Information
This field is hidden when viewing the form
Is this visit related to an accident?
(Required)
No
Yes
This field is hidden when viewing the form
please specify if AUTO or Other
This field is hidden when viewing the form
Is this visit related to a work-related accident?
(Required)
No
Yes
This field is hidden when viewing the form
please provide Workman’s Comp Ins.
This field is hidden when viewing the form
Primary Insurance
(Required)
This field is hidden when viewing the form
Policy Holder Name
(Required)
This field is hidden when viewing the form
Policy Holder’s Employer
(Required)
This field is hidden when viewing the form
Policy Holder’s SSN
(Required)
This field is hidden when viewing the form
Group#
(Required)
This field is hidden when viewing the form
Policy ID#
(Required)
This field is hidden when viewing the form
Policy Holder’s DOB
(Required)
MM slash DD slash YYYY
This field is hidden when viewing the form
Client’s Relationship to Policy Holder
Self
Spouse
Other
This field is hidden when viewing the form
Other
This field is hidden when viewing the form
Secondary Insurance
This field is hidden when viewing the form
Policy Holder Name
This field is hidden when viewing the form
Policy Holder’s Employer
This field is hidden when viewing the form
Policy Holder’s SSN
This field is hidden when viewing the form
Group#
This field is hidden when viewing the form
Policy ID#
This field is hidden when viewing the form
Policy Holder’s DOB
MM slash DD slash YYYY
This field is hidden when viewing the form
Client’s Relationship to Policy Holder
Self
Spouse
Other
This field is hidden when viewing the form
Other
Financial Obligation.
I agree that I am financially responsible for payment of all amounts due for services provided by Obur Health, P.A. and/or its employees or independent contractors. I understand that I am responsible for paying for services regardless of whether I have insurance coverage or if other parties are also responsible for my care. I will not be responsible for payment if my financial obligation is waived due to contractual agreements between Obur Health, P.A. and my insurer, or if prohibited by law. In the event of collection, I agree that the costs of collection, including attorney’s fees and court costs, will be added to my financial obligation to Obur Health, P.A.. This agreement is governed by Texas law, and I agree that venue and agree will be in Greene County, Texas.
Certification.
I certify that I have read all parts of this Authorization, Financial Obligation, and the Consent for Services. I accept all the terms and conditions, confirm that all representations I have made are true, and agree that a copy of this form is as valid as the original. This form is effective for one year unless I revoke it in writing.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Relationship to Client
(Required)
(if signed by a parent, legal guardian, or representative)
