Patient Financial & Fee Agreement

Patient Financial and Fee Agreement 

Due to insurance carriers’ tardiness in regards to service claims submitted by providers, please read the following information: If your insurance company does not respond in a timely fashion a “Statement” will be released to you. Upon receipt of the “Statement” we suggest that you contact your insurance carrier and request that they process your claim. 

Should you receive any correspondence from your insurance company in regards to your services in this office, you must respond to that correspondence immediately, in order to have the claim processed and paid. 

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay a fixed allowance for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance at the time of service. 

Patient’s or authorized person’s signature: I authorize the release of any medical or other information necessary to process my insurance claim. 

Insured’s or authorized person’s signature: I authorize payment of medical benefits to the provider for services. I fully understand that, regardless of insurance coverage, I am legally responsible for all fees due the doctor.