Patient Declaration – Insurance Authorisation

Name(Required)

First Last

Date of Birth(Required)

Insurance name(Required)

Membership Number(Required)

Authorization Number(Required)

Treatment Location: The London General Practice, 114A Harley street, London W1G 7JL

Doctors name(Required)

Treatment Date(Required)

Condition authorised by insurance company(Required)

I confirm that my insurance company has issued a pre-authorisation in relation to my treatment.

Declaration(Required)

I Understand that pre-authorisation is not a guarantee of full payment

Coverage is subject to policy terms, eligibility, and medical necessity

I am responsible for any deductibles, excess, co-payments, or non-covered costs

If my insurance Company declines or partially pays, I will settle any outstanding balance

I authorise the clinic to submit claims and share relevant medical and billing information with my insurance company.

Data Protection (UK GDPR)

My personal and health data will be processed in accordance with the UK GDPR and the Data Protection Act 2018 for treatment, insurance claims processing, and administration.

Signature(Required)

Please acknowledge(Required)

By typing my signature below I agree to be legally bound by this document.

Typed Signature(Required)

Date(Required)