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Home
For Patients
Home visit
Televisit
In-clinic
For Health Care Providers
Register as a Healthcare provider
Provider documentation
Services
Home
For Patients
Home visit
Televisit
In-clinic
For Health Care Providers
Register as a Healthcare provider
Provider documentation
Services
X
Contact Number
832-730-4479
Home
For Patients
Home visit
Televisit
In-clinic
For Health Care Providers
Register as a Healthcare provider
Provider documentation
Services
X
Patient Registration
Name
(Required)
First
Middle
Last
Today’s Date
(Required)
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Date of Birth (MM/DD/YYYY)
(Required)
Sex Assigned at Birth
(Required)
Marital Status
(Required)
Single
Married
Divorced
Widowed
Separated
Other Information
Name of Employer
Work Phone
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Emergency Contact Name
Emergency Contact Phone
Insurance Information
Is this visit related to an accident?
(Required)
No
Yes
please specify if AUTO or Other
Is this visit related to a work-related accident?
(Required)
No
Yes
please provide Workman’s Comp Ins.
Primary Insurance
(Required)
Policy Holder Name
(Required)
Policy Holder’s Employer
(Required)
Policy Holder’s SSN
(Required)
Group#
(Required)
Policy ID#
(Required)
Policy Holder’s DOB
(Required)
Client’s Relationship to Policy Holder
Self
Spouse
Other
Other
Secondary Insurance
Policy Holder Name
Policy Holder’s Employer
Policy Holder’s SSN
Group#
Policy ID#
Policy Holder’s DOB
Client’s Relationship to Policy Holder
Self
Spouse
Other
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 Harris 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)
Your Name
Your Name
Your Name
Your Name
Date
(Required)
Relationship to Client
(Required)
(if signed by a parent, legal guardian, or representative)
Message Box (appointment request or general question)
Non-Insured Patient Payment Form
Patient Registration
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Today’s Date
(Required)
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)
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Date of Birth (MM/DD/YYYY)
(Required)
Sex Assigned at Birth
(Required)
Marital Status
(Required)
Single
Married
Divorced
Widowed
Separated
Other Information
Name of Employer
Work Phone
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Emergency Contact Name
Emergency Contact Phone
Insurance Information
Is this visit related to an accident?
(Required)
No
Yes
please specify if AUTO or Other
Is this visit related to a work-related accident?
(Required)
No
Yes
please provide Workman’s Comp Ins.
Primary Insurance
(Required)
Policy Holder Name
(Required)
Policy Holder’s Employer
(Required)
Policy Holder’s SSN
(Required)
Group#
(Required)
Policy ID#
(Required)
Policy Holder’s DOB
(Required)
Client’s Relationship to Policy Holder
Self
Spouse
Other
Other
Secondary Insurance
Policy Holder Name
Policy Holder’s Employer
Policy Holder’s SSN
Group#
Policy ID#
Policy Holder’s DOB
Client’s Relationship to Policy Holder
Self
Spouse
Other
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 Harris 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)
Your Name
Your Name
Your Name
Your Name
Date
(Required)
Relationship to Client
(Required)
(if signed by a parent, legal guardian, or representative)
Message Box (appointment request or general question)
Non-Insured Patient Payment Form
Patient Registration
Non-Insured Patient Payment Form
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Today’s Date
(Required)
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)
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Date of Birth (MM/DD/YYYY)
(Required)
Sex Assigned at Birth
(Required)
Marital Status
(Required)
Single
Married
Divorced
Widowed
Separated
Other Information
Name of Employer
Work Phone
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Emergency Contact Name
Emergency Contact Phone
Insurance Information
Is this visit related to an accident?
(Required)
No
Yes
please specify if AUTO or Other
Is this visit related to a work-related accident?
(Required)
No
Yes
please provide Workman’s Comp Ins.
Primary Insurance
(Required)
Policy Holder Name
(Required)
Policy Holder’s Employer
(Required)
Policy Holder’s SSN
(Required)
Group#
(Required)
Policy ID#
(Required)
Policy Holder’s DOB
(Required)
Client’s Relationship to Policy Holder
Self
Spouse
Other
Other
Secondary Insurance
Policy Holder Name
Policy Holder’s Employer
Policy Holder’s SSN
Group#
Policy ID#
Policy Holder’s DOB
Client’s Relationship to Policy Holder
Self
Spouse
Other
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 Harris 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)
Your Name
Your Name
Your Name
Your Name
Date
(Required)
Relationship to Client
(Required)
(if signed by a parent, legal guardian, or representative)
Message Box (appointment request or general question)
