WAIVER OF LIABILITY AND FINANCIAL POLICY


We welcome you into our medical office. Our goal is to provide with the best medical care you deserve. Sometimes this requires referral to specialists, lab work, or other testing that your insurance may not agree to cover. In order to receive your full benefits, you may need to go to a provider contracted with your insurance company. Our staff will work with you to help you understand your insurance requirements so that you may not incur additional charges.

Please understand, this waiver you are signing states that your insurance company may not cover the services you are being rendered today or in the future. If these services are denied, you will be responsible for payment

This office will bill your insurance carriers on your behalf with the understanding that the final responsibility for payment of the account rests with the patient. Although we work closely with the patient regarding the settlement of liability and other insurance claims, it is done so only as a convenience to the patient in settling his/her medical account. Our filing of the insurance claims on the patient’s behalf does not relieve the patient of the final responsibility for settling his/her account.


BENEFICIARY’S ACKNOWLEDGEMENT AND AGREEMENT TO PAY


I agree to provide payment in full for the services rendered to me in the event that my insurance company denies payment. My physician has notified me of the possibility that certain services may or may not be covered by my insurance.


OTHER INSURANCE

If my workers’ compensation or auto insurance does not pay my account for any reason, I will be responsible for the payment in full.


MANAGED CARE FINANCIAL POLICY

We will bill your managed care company. All payments for deductibles, co-insurance, co-payments and non-covered services, which you elect to receive, are due at the time of service.