Appointments: 704.377.0246     General: 704.377.4009
Referring MDs MyChart Online Payment Center

    I authorize any holder of medical or other information about me to release to insurance carriers, the Social Security Administration and Health Care Financing Administration (or its intermediaries or carrier), and/or any physician Charlotte Gastroenterology & Hepatology refers me to, or any information needed for this or a related insurance and/or medical claim.

    I hereby assign to the physicians all payments for hospital/medical/surgical services rendered to myself or my dependents.

    I understand that I am responsible for any amount not paid by insurance.

    I understand that Charlotte Gastroenterology & Hepatology, PLLC accepts Medicare assignment for Medicare claims and all regulations pertaining to Medicare assignment and benefits apply.