Purple Amphibian, PLLC, Consent Form / Notification of Surgical Assistant

- Virginia Austin, CRNFA of Purple Amphibian, PLLC, has been requested by your surgeon. She is a skilled first assist with more than 20 years of experience. Ask your surgeon or refer to www.purpleamphibian.com or use the QR code to learn more about her role in your care.  Purple Amphibian, PLLC, requires a prepayment for your surgery. Purple Amphibian, PLLC, will file a claim with your insurance company several weeks after your procedure for the remainder of your allowable deductable/coinsurance. Please note insurance companies can take several months to complete the claims process.
- I authorize the release of medical or other information necessary to process a claim for medical services.
- I hereby authorize Purple Amphibian, PLLC/Virginia Austin, CRNFA, to bill my insurance carrier. I may receive an explanation of benefits (EOB) from my insurance company and understand Purple Amphibian, PLLC, is requesting payment for my surgery.  I further understand any payment made to Purple Amphibian, PLLC, by my insurance carrier is payment to Purple Amphibian, PLLC above and beyond my prepay.
- I authorize payment to be made directly to Purple Amphibian, PLLC, on my behalf.
- I authorize Purple Amphibian, PLLC, to file an appeal on my behalf if insurance does not pay appropriately.
- I authorize that Purple Amphibian, PLLC/Virginia Austin, CRNFA, to be involved in my care. I understand this health care provider is not a participating provider in my health insurance coverage network.
- I hereby agree in advance, by signing below, to accept full financial responsibility for all costs associated with any deductible, co-insurance amount, or non-covered medical services provided by Virginia Austin, CRNFA.